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Fundamentals of Nursing The Art and Science of
Person-Centered Care 10th Edition Taylor Lynn Bartlett Test
Bank
Introduction to Clinical Nursing Practice (University of Southern Mississippi)
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Fundamentals of Nursing The Art and Science of Person-Centered Care 10th Edition Taylor
Lynn Bartlett Test Bank
Chapter 1, Introduction to Nursing and Professional Formation
A)
Clinical nurse specialist
B)
Nurse entrepreneur
C)
Nurse practitioner
D)
Nurse educator
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1.
An oncology nurse with 15 years of experience, certification in the area of oncology
nursing, and a master’s degree is considered to be an expert in her area of practice
and works on an oncology unit in a large teaching hospital. Based upon this
description, which of the following career roles best describes this nurse’s role, taking
into account her
qualifications and experience?
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Ans: A
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A clinical nurse specialist is a nurse with an advanced degree, education, or
experience who is considered to be an expert in a specialized area of nursing. The
clinical nurse specialist carries out direct patient care; consultation; teaching of
patients, families, and staff; and research. A nurse practitioner has an advanced
degree and works in a variety of settings to deliver primary care. A nurse educator
usually has an advanced degree and teaches in the educational or clinical setting. A
nurse entrepreneur may manage a clinic or health-related business.
2.
What guidelines do nurses follow to identify the patient’s health care needs and strengths, to
establish and carry out a
plan of care to meet those needs, and to evaluate the effectiveness of the plan to meet
established outcomes?
A)
Nursing process
B)
ANA Standards of Professional Performance
C)
Evidence-based practice guidelines
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D)
Nurse Practice Acts
Ans: A
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The nursing process is one of the major guidelines for nursing practice. Nurses
implement their roles through the nursing process. The nursing process is used by the
nurse to identify the patient’s health care needs and strengths, to establish and carry
out a plan of care to meet those needs, and to evaluate the effectiveness of the plan to
meet established outcomes.
A)
American Nurses Association (ANA)
B)
American Association of Colleges in Nursing (AACN)
C)
National League for Nursing (NLN)
D)
International Council of Nurses (ICN)
Ans: A
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3.
Which of the following organizations is the best source of information when a nurse wishes to
determine whether an
action is within the scope of nursing practice?
Feedback:
The ANA produces the 2003 Nursing: Scope and Standards of Practice, which
defines the activities specific and unique to nursing. The AACN addresses
educational standards, while the NLN promotes and fosters various aspects of
nursing.
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The ICN provides a venue for national nursing organizations to collaborate, but does
not define standards and scope of practice.
Who is considered to be the founder of professional nursing?
A)
Dorothea Dix
B)
Lillian Wald
C)
Florence Nightingale
D)
Clara Barton
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Florence Nightingale is considered to be the founder of professional nursing. She
elevated the status of nursing to a respected occupation, improved the quality of
nursing care, and founded modern nursing education. Although the other choices are
women who were important to the development of nursing, none of them is
considered the founder.
Which of the following nursing pioneers established the Red Cross in the United States in
1882?
A)
Florence Nightingale
B)
Clara Barton
C)
Dorothea Dix
D)
Jane Addams
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Ans: B
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Clara Barton volunteered to care for wounds and feed union soldiers during the civil
war, served as the supervisor of nurses for the Army of the James, organized hospitals
and nurses, and established the Red Cross in the United States in 1882.
6.
A nurse practitioner is caring for a couple who are the parents of an infant diagnosed with
Down Syndrome. The nurse
makes referrals for a parent support group for the family. This is an example of which nursing
role?
Teacher/Educator
B)
Leader
C)
Counselor
D)
Collaborator
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Counseling skills involve the use of therapeutic interpersonal communication skills to
provide information, make appropriate referrals, and facilitate the patient’s problemsolving and decision-making skills. The teacher/educator uses communication skills
to assess, implement, and evaluate individualized teaching plans to meet learning
needs of clients and their families. A leader displays an assertive, self-confident
practice of nursing when providing care, effecting change, and functioning with
groups. The collaborator uses skills in organization, communication, and advocacy to
facilitate the functions of all members of the health care team as they provide patient
care.
7.
A nurse is providing nursing care in a neighborhood clinic to single, pregnant teens. Which of
the following actions is
the best example of using the counselor role as a nurse?
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A)
Discussing the legal aspects of adoption for teens wishing to place their infants with a family
B)
Searching the Internet for information on child care for the teens who wish to return to school
C)
Conducting a client interview and documenting the information on the client’s chart
D)
Referring a teen who admits having suicidal thoughts to a mental health care specialist
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Ans: D
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The role of the counselor includes making appropriate referrals. Discussing legal
issues is the role of the advocate and searching for information on the Internet is the
role of a researcher. Conducting a client interview would fall under the role of the
caregiver.
A)
Health is a state of optimal functioning.
B)
Health is an absence of illness.
C)
Health is always an objective state.
D)
Health is not determined by the patient.
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8.
A nurse instructor explains the concept of health to her students. Which of the following
statements accurately describes
this state of being?
Ans: A
Feedback:
Health is a state of optimal functioning or well-being. As defined by the World
Health Organization, one’s health includes physical, social, and mental components
and is not merely the absence of disease or infirmity. Health is often a subjective
state; a person may be medically diagnosed with an illness but still consider himself
or herself healthy.
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A)
Cancer
B)
Obesity
C)
Diabetes
D)
Hypertension
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9.
A nurse incorporates the health promotion guidelines established by the U.S. Department of
Health document: Healthy
People 2010. Which of the following is a health indicator discussed in this document?
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The 10 leading indicators of health established by Healthy People 2010 are: physical
activity, excessive weight and obesity, tobacco use, substance abuse, responsible
sexual behavior, mental health, injury and violence, environmental quality,
immunizations, and access to health care.
Which of the following is a criteria that defines nursing as profession?
A)
an undefined body of knowledge
B)
a dependence on the medical profession
C)
an ability to diagnose medical problems
D)
a strong service orientation
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Ans: D
Feedback:
Nursing is recognized increasingly as a profession based on the following defining
criteria: well-defined body of specific and unique knowledge; strong service
orientation; recognized authority by a professional group; code of ethics; professional
organization that sets standards; ongoing research; and autonomy.
A)
Enrolling in an advanced degree program
B)
Filing NCLEX results in the county of residence
C)
Being licensed by the State Board of Nursing
D)
Having a signed letter confirming graduation
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11.
After graduation from an accredited program in nursing and successfully passing the NCLEX,
what gives the nurse a
legal right to practice?
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Ans: C
The Board of Nursing in each state has the legal authority to allow graduates of
approved schools of nursing to take the licensing examination. Those who
successfully meet the requirements for licensure are given a license to practice
nursing in the state. It is illegal to practice nursing without a license issued by the
State Board of Nursing. A nurse does not have the legal right to practice nursing by
enrolling in an advanced degree program, filing NCLEX results, or having a letter
confirming graduation.
12.
A health care facility determined that a nurse employed on a medical unit was
documenting care that was not being given, and subsequently reported the action to
the State Board of Nursing. How might this affect the nurse’s license to
practice nursing?
A)
It will have no effect on the ability to practice nursing.
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B)
The nurse can practice nursing at a less-skilled level.
C)
The nurse’s license may be revoked or suspended.
D)
The nurse’s license will permanently carry a felony conviction.
Ans: C
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The license and the right to practice nursing can be denied, revoked, or suspended for
professional misconduct, such as a crime. Other areas of professional misconduct
include incompetence, negligence, and chemical impairment. Committing a felony
does affect the legal right to practice nursing, does not allow the nurse to practice at a
lower level, and is not attached to the license.
A)
evaluation
B)
implementation
C)
planning
D)
nursing
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13.
While providing care to the diabetic patient the nurse determines that the patient has a
knowledge deficit regarding
insulin administration. This nursing action is described in which phase of the nursing process?
diagnosis Ans:
D
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Feedback:
Nursing focuses on human responses to actual or potential health problems.
Identifying the problems occur in the nursing diagnosis phase. Mutually establishing
expected outcomes with the patient occurs in the planning phase. Implementation of
the individualized interventions, and evaluation of outcomes are also phases in the
nursing process.
A)
Caring
B)
Comforting
C)
Counseling
D)
Assessment
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14.
A nurse is caring for a client who is a chronic alcoholic. The nurse educates the client
about the harmful effects of alcohol and educates the family on how to cope with the
client and his alcohol addiction. Which of the following skills is
the nurse using?
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The nurse is using counseling skills to educate the client about the harmful effects of
alcohol. The nurse can also suggest rehabilitative care for the client. The nurse uses
therapeutic communication techniques to encourage verbal expression and to
understand the client’s perspective. Caring, comforting, and assessment may require
active listening, but counseling is based upon the active listening and interaction
between the client and the counselor.
15.
A nurse is caring for a client with quadriplegia who is fully conscious and able to
communicate. What skills of the nurse
would be the most important for this client?
A)
Comforting
B)
Assessment
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C)
Counseling
D)
Caring
Ans: D
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The client needs assistance in performing activities of daily life. This would require
implementation of caring skills from the nurse. Comforting, counseling, and
assessment skills are also required, but the priority is the caring skill. Comforting
skills involve providing safety and security to the client, whereas counseling skills are
implemented while providing health education and emotional support. Assessment
skills would be required when collecting data from the client.
A)
Assessment
B)
Caring
C)
Comforting
D)
Counseling
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16.
A nurse is assigned the care of a client who has been admitted to the health care facility with
high fever. Which nursing
skill should be put into practice at the first contact with the client?
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On admission of the client to a health care facility, the nurse would be required to
conduct an initial assessment of the client. Therefore, the nurse would implement his
or her nursing skills in this case. This can be done by interviewing, observing, and
examining the client. Caring skills are put into practice once the nursing needs are
determined.
Comforting and counseling skills may not have a major role in assessing client problems.
A)
“Open hernioplasty is the best surgery for you.”
B)
“Open and laparoscopic hernioplasty are available.”
C)
“You are not a suitable candidate for hernioplasty.”
D)
“I had a bad experience when I underwent hernioplasty.”
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17.
A nurse is caring for a client with a hernia. Which of the following statements should the nurse
use while counseling the
client about his condition?
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A counselor should provide the client with unbiased information from which to
choose. Therefore, the statement that “Open and laparoscopic hernioplasty are
available” should be used by the nurse when counseling a client with hernia. The
nurse should, however, refrain from giving a personal opinion, so it should not be
mentioned which surgery is best for the client; likewise, the nurse should not bring
up his or her own past experiences. By reserving personal opinions, a nurse promotes
the right of every person to make his or her own decisions and choices on matters
affecting health and illness care. Telling the client about his suitability to surgery or
the best surgery for him may be biased from the experiences of the past.
18.
A registered nurse assigns the task of tracheostomy suctioning of a client to the LPN.
The LPN informs the nurse that she has never done the procedure practically on a
client. What should be the most appropriate response from the
registered nurse?
A)
“You are through with your theory class, so you should know.”
B)
“Take the help of the nurse who knows to perform the procedure.”
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C)
“Take the help of the procedure manual and act accordingly.”
D)
“I will help you in performing the procedure on the client.”
Ans: D
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Although the registered nurse has assigned the task to the LPN, the overall
responsibility lies with the registered nurse. The registered nurse is answerable for the
client’s care, not the LPN. Telling the LPN that she should know the procedure
because it is taught in class is inappropriate; putting theory into application would
require supervision. Asking the LPN to refer to the manual and perform the
procedure is incorrect because the LPN may commit mistakes. The LPN is not
confident about the procedure and therefore should not be asked to do the task alone
or with another nurse who knows the procedure.
A)
Educating a group of young girls about AIDS
B)
Telling a client to localize the pain in his abdomen
C)
Encouraging a client to walk without support
D)
Assisting a lactating mother in feeding her child
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19.
A nurse at a health care facility provides information, assistance, and encouragement to clients
during the various phases
of nursing care. In which of the following activities does the nurse use counseling skills?
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Ans: A
Feedback:
The activity of educating a group of young girls about AIDS is based on the nurse
using counseling skills. Telling a client to localize his pain is an assessment skill.
Encouraging a client to walk without support can be both a comforting skill and a
caring skill. Assisting a lactating mother in feeding her baby is an example of a
caring skill.
A)
Hospital-based diplomas
B)
Baccalaureate nursing programs
C)
Associate degree programs
D)
Continuing nursing programs
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20.
A student wants to join a nursing program that provides flexibility in working at both staff and
managerial positions.
Which nursing program should the nurse suggest for this student?
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Ans: B
Feedback:
The student could opt for a baccalaureate nursing program. Baccalaureate-prepared
nurses have the greatest flexibility in qualifying for nursing positions at both staff and
managerial levels. Hospital-based diploma programs are three-year courses and
provide maximum exposure to clinical nursing. Students becoming nurses through the
associate degree program would not be expected to work in a management position.
Continuing nursing programs are on-the-job educational programs.
21.
A)
Training schools for nurses were established in the United States after the Civil War. The
standards of U.S. schools
deviated from those of the Nightingale paradigm. Which of the following statements is true
about U.S. training schools?
Training schools were affiliated with a few select hospitals.
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B)
Training of nurses provided no financial advantages to the hospital.
C)
Training was formal, based on nursing care.
D)
Training schools eliminated the need to pay employees.
Ans: D
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Training schools in the U.S. profited by eliminating the need to pay employees
because students worked without pay in return for training, which usually consisted
of chores. U.S. training schools were established by any hospital; there was no
formal training. Training was an outcome of work, which eliminated the need to pay
employees. Nightingale training schools were affiliated with a few select hospitals,
training of nurses provided no financial advantages to the hospital, and the training
was formal, based on nursing care.
A)
It fosters continued improvement in nursing education programs.
B)
Accreditation is by governmental peer review process.
C)
It ensures the quality and integrity of diploma nursing programs.
D)
It uses state-recognized standards to evaluate the programs.
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22.
A student has completed a nursing program accredited by the Commission on Collegiate
Nursing Education. Which of
the following is true about the organization?
Ans: A
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Feedback:
The Commission on Collegiate Nursing Education fosters continued improvement in
nursing education programs. Accreditation is by nongovernmental, peer review
process. It ensures the quality and integrity of baccalaureate and graduate nursing
programs, not diploma nursing programs. It uses nationally-recognized, not staterecognized, standards to evaluate the programs.
A)
Assessment
B)
Diagnosis
C)
Evaluation
D)
Collaboration
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23.
A registered nurse adheres to the American Nurses Association’s standard of professional
performance by engaging in
which of the following?
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Collaboration is designated in ANA’s standard of professional performance.
Assessment, diagnosis, and evaluation are not designated in ANA’s standard of
professional performance. They are professional nursing responsibilities designated in
ANA’s standard of care list.
24.
During the clinical rotation, a nurse documents the vital signs of a client on the bedside chart.
What role is the nurse
playing in such a situation?
A)
Decision maker
B)
Communicator
C)
Coordinator
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D)
Client advocate
Ans: B
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The nurse is providing, in written form, the client’s vital signs to the health care
provider checking the bedside chart during his or her clinical rounds, so the nurse acts
as a communicator. The nurse is not making any decisions here, so the role is not that
of a decision maker. The nurse is not playing the role of a coordinator or a client
advocate. When the nurse coordinates services offered by a variety of health care
professionals, the nurse acts as a coordinator. As a client advocate, the nurse should
protect the client, understanding the client’s needs and concerns.
A licensed practice nurse (LPN) is working as a staff nurse. What role do the LPNs working
as staff nurses play?
A)
Work only in long-term care facilities and at client’s homes
B)
Provide direct nursing care to the clients in the health care facility
C)
Work only as care providers, team members, and communicators
D)
Supervise the work of charge nurses working in different units
Ans: B
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25.
Feedback:
LPNs working as staff nurses provide direct nursing care to the clients in the health
care facility. Staff nurses may work in hospitals, the community, clinics, long-term
care facilities, or homes. They work not only as care providers, team
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members, and communicators but also as decision makers, client advocates, and
educators. They do not supervise the work of charge nurses working in different
units. Their work is coordinated by the charge nurse or the team leader.
The Nurse Corps of the United States Army was established by whom?
A)
Dorothea Dix
B)
Lillian Wald
C)
Florence Nightingale
D)
Isabel Hampton Robb
Ans:
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Dorothea Dix established the Nurse Corps of the United States Army.
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27.
The director of nursing (DON) of a major hospital is seeking to hire a nurse with a strong
technical background to care
for patients on a busy surgical unit. The DON is most likely going to hire a nurse prepared at
which level of nursing?
A)
Doctoral level
B)
Master’s level
C)
Baccalaureate level
D)
Associate level
Ans: D
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The ANA’s 1965 resolution prompted the 1985 ANA statement adopting the titles of
associate nurse (a nurse prepared in an associate degree program with an emphasis
on technical practice) and professional nurse (a nurse possessing the baccalaureate
degree in nursing) for these two levels. Master’s and doctoral prepared nurses
possess higher degrees and expertise.
Licensed practical nursing program
B)
Certification in a nursing specialty
C)
Diploma nursing program
D)
Baccalaureate program
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28.
A student is choosing her educational path and desires a nursing degree with a track that
contains community nursing
and leadership, as well as liberal arts. The student would best be suited in which type of
program?
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Ans: D
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The baccalaureate degree in nursing offers students a full college or university
education with a background in the liberal arts.
29.
A nurse is caring for a young victim of a terrorist attack. During the rehabilitative process, the
nurse assists the client in
bathing and dressing. What role the nurse is engaged in?
A)
Advocate
B)
Caregiver
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C)
Counselor
D)
Educator
Ans: B
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As providers of care, nurses assume responsibility for helping clients promote,
restore, and maintain health and wellness. Communicating the client’s needs and
concerns, and protecting the client’s rights are components of the advocacy role of
nursing. The nurse is simply assisting in hygiene measures; no education or
counseling is being provided.
A)
Communicator
B)
Advocate
C)
Caregiver
D)
Researcher
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30.
A nurse receives an x-ray report on a newly admitted patient suspected of having a fractured
tibia. The nurse contacts
the physician to report the findings. What role is the nurse engaged in?
Feedback:
Nurses are communicators when they report findings to the health care team.
Advocacy involves actions such as protecting the patient’s safety or rights.
Administering care measures directly to the patient demonstrates the caregiver role.
Research involves collecting and analyzing data.
31.
The client’s plan of care is created by the nurse using which guideline for nursing practice?
A)
Nursing process
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B)
Nursing’s Social Policy Statement
C)
Nurse practice act
D)
ANA Standards of Nursing Practice
Ans: A
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Nursing process is used by nurses to identify the client’s strengths, limitations, and
health care needs; to formulate a plan of care to address the health care needs; to plan
and implement a plan of care to meet those health care needs; and to evaluate the
effectiveness of the plan to achieve established outcomes. The ANA Standards of
Nursing Practice defines the activities of nurses that are specific and unique to
nursing. Nurse practice acts are laws established by each state to regulate the practice
of nursing. Nursing’s Social Policy Statement describes the values and social
responsibility of nursing, provides a definition and scope of practice for nursing and
nursing’s knowledge base, including the methods by which nursing is regulated.
A)
Illness prevention
B)
Restorative care
C)
Treatment of disease
D)
Supportive nursing care
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32.
The nurse is administering immunizations to a group of teens in a county health clinic. The
nurse correctly identifies this
action as:
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Ans: A
Feedback:
The aim of illness prevention activities is to reduce the risk for illness, to promote
good health habits, and to maintain optimal functioning. Immunization administration
is an example of illness prevention. Assisting with crutch walking, and teaching
medication administration would be examples of health restoration activities.
Administering antibiotics to a patient to treat an infection would be an example of
treatment of disease. Hospice care is an example of supportive care.
A)
Advocate
B)
Leader
C)
Counselor
D)
Researcher
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33.
Which nursing role is the nurse exhibiting when collecting data about the number of urinary
tract infections on the
nursing unit?
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Ans: D
Feedback:
Data collection is part of the research process. As an advocate, the nurse would
implement actions to protect the rights of the client. Counseling involves the use of
therapeutic, interpersonal communication skills to provide information, make
appropriate referrals, and facilitate client problem-solving and decision-making skills.
A nurse leader is assertive and self-confident when providing care, effecting change,
and functioning within groups.
34.
A client reports to the emergency department with ankle pain from a minor road
accident. The nurse asks the client to fully describe the circumstances of the accident.
Which ANA standard of nursing practice is best demonstrated by the
nurse’s action?
A)
Assessment
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B)
Diagnosis
C)
Ethics
D)
Caring
Ans: A
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According to the ANA Standard I, the registered nurse collects comprehensive data
pertinent to the client’s health or the situation. Standard 2 – Diagnosis is Standard 2,
which occurs when the registered nurse analyzes the assessment data to determine
the diagnoses or issues pertaining to the client. Standard 7 – Ethics pertains to the
ethical guidelines of nursing practice. Caring, although an essential part of nursing
practice, is not considered an ANA Standard.
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Organize these events in chronological order, beginning with the earliest (1) and ending with
the most recent (5).
During the Crusades, religious orders provided nursing care to the sick.
2)
Florence Nightingale administered care to British soldiers during the Crimean War.
3)
Clara Barton organized the American Red Cross.
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1)
4) Mary Elizabeth Mahoney graduated from the New England Hospital for Women
and Children in 1879 as America’s first African American nurse.
35.
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1, 2, 3, 4, 5
B)
1, 2, 4, 3, 5
C)
1, 2, 4, 5, 3
D)
1, 2, 3, 5, 4
E)
2, 1, 4, 3, 5
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5) Margaret Sanger advocated for contraception and family planning in the United States.
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The correct order of these events is (1) during the Crusades, religious orders
provided nursing care to the sick; (2) Florence Nightingale administered care to
British soldiers during the Crimean War; (3) Clara Barton organized the American
Red Cross; (4) Mary Elizabeth Mahoney graduated from the New England Hospital
for Women and Children in 1879 as America’s first African American nurse; and (5)
Margaret Sanger advocated for contraception and family planning in the United
States.
1.
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Chapter 2, Theory, Research, and Evidence- Based Practice
After reviewing several research articles, the clinical nurse specialist on a medical surgical
unit rewrites the procedure
on assessing placement of a nasogastric tube. What source of nursing knowledge did the nurse
use in this situation?
A)
Scientific knowledge
B)
Traditional knowledge
C)
Authoritative knowledge
D)
Philosophical knowledge
Ans: A
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Feedback:
The clinical nurse specialist utilized scientific knowledge, which is gained through
the research-based scientific method. Philosophical knowledge is not a source of
nursing knowledge, but is a type of general knowledge. Authoritative knowledge
comes from an expert and is accepted as truth based upon the person’s perceived
expertise. Traditional knowledge is that part of nursing practice passed down from
generation to generation and is not based upon scientific inquiry.
A)
General systems theory
B)
Nursing theory
C)
Adaptation theory
D)
Developmental theory
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2.
Which of the following theories emphasizes the relationships between the whole and the parts,
and describes how parts
function and behave?
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General systems theory describes how to break whole things into parts and then learn
how the parts work together in “systems.” Nursing theory attempts to describe,
explain, predict, and control desired outcomes of nursing care practices. Adaptation
theory defines adaptation as the adjustment of living matter to other living things and
to environmental conditions. Developmental theory outlines the process of growth
and development of humans as orderly and predictable.
A)
Qualitative research
B)
Quantitative research
C)
Basic research
D)
Applied research
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3.
A nurse researcher is studying perceptions of vocational rehabilitation for clients after a spinal
cord injury. What type of
research method will be used to study the perceptions of this group of individuals?
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The nurse researcher will use qualitative research methods to investigate perceptions,
and the researcher will analyze words instead of numbers, which are analyzed in
quantitative research. Basic and applied research are quantitative research methods.
4.
A staff development nurse is asking a group of new staff nurses to read and be
prepared to discuss a qualitative study that focuses on nursing events of the past.
This is done in an attempt to increase understanding of the nursing profession
today. What method of qualitative research is used in this article?
A)
Historical
B)
Phenomenology
C)
Grounded theory
D)
Ethnography
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Ans: A
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This article uses historical methodology, which examines events of the past to
increase understanding of the nursing profession today. Phenomenology is used to
describe experiences as they are lived by the subjects being studied.
Grounded theory is the discovery of how people describe their own reality and how
their beliefs are related to their actions in a social scene. Ethnography is used to
examine issues of a culture that are of interest to nursing.
A)
The conceptual and theoretical basis for nursing practice came from outside the profession.
B)
Nurses were too busy working in practice to increase the public awareness associated with the
role of the nurse.
C)
Nurses spent most of their time in laboratory settings conducting research.
D)
Women were independent and refused to work collectively.
Ans: A
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5.
In understanding the historical influences on nursing knowledge, nursing as a profession
struggled for years to establish
its own identify and to receive recognition for its contributions to health care. Why?
Feedback:
Despite Florence Nightingale’s belief in the uniqueness of nursing, the training of
nurses was initially carried out under the direction and control of the medical
profession. Because the conceptual and theoretical basis for nursing practice
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came from outside the profession, nursing struggled for years to establish its own
identify and to receive recognition for its significant contributions to health care.
A)
Correlational research
B)
Descriptive research
C)
Quasi-experimental research
D)
Experimental research
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6.
An obstetrical nurse wishes to identify whether clients’ perceptions of a high level of
support from their partner is associated with a decreased length of the second stage of
labor. Which type of quantitative research is most appropriate
for this research question?
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Correlational quantitative research is used to examine relationships between two or
more variables. In this case, the variables are perceptions of partner support and
length of Stage 2 labor. There is no manipulation of the variables as there would be
in an experimental or quasi-experimental study. The focus on the relationship
between the two variables goes beyond simple description of events.
7.
Nurse researchers have predicted that a newly created mentorship program will
result in decreased absenteeism, increased retention, and decreased attrition among a
hospital’s nursing staff. Which of the following does this predicted
relationship represent?
A)
Hypothesis
B)
Dependent variable
C)
Abstract
D)
Methodology
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Ans: A
Feedback:
A hypothesis is an expected statement of the relationship between variables in a
study. In this study, the dependent variables are absenteeism, retention, and attrition
while the independent variable is the mentorship program. The methodology of a
study is the logistical framework that guides the planning and execution of the study.
An abstract is a summary of a research study published in a journal.
The practice of changing patients’ bedclothes each day in acute care settings is an example of
what type of knowledge?
A)
Authoritative
B)
Traditional
C)
Scientific
D)
Applied
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8.
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Ans: B
Changing bedclothes daily in acute care settings is an example of traditional
knowledge. The practice is not based on research findings, but is rather a part of
nursing practice passed down from generation to generation.
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A)
Authoritative
B)
Traditional
C)
Scientific
D)
Applied
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9.
A student nurse learns how to give injections from the nurse manager. This is an example of
the acquisition of what type
of knowledge?
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Authoritative knowledge comes from an expert and is accepted as truth, based on the
person’s perceived expertise. Authoritative knowledge generally remains
unchallenged as long as the presumed authority maintains his or her perceived
expertise.
A)
Science
B)
Philosophy
C)
Process
D)
Virtue
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10.
A client undergoing chemotherapy for a brain tumor believes that having a good attitude will
help in the healing process.
This is an example of what type of knowledge?
Ans: B
Feedback:
Philosophy is the study of wisdom, fundamental knowledge, and the processes used
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to develop and construct one’s perceptions of life. Philosophy provides a viewpoint
and implies a system of values and beliefs. Each individual develops a personal
philosophy to give meaning to experiences and to guide behavior and attitudes.
Personal philosophies are developed by learning from interpersonal relationships,
through formal and informal educational experiences, through religion and culture,
and from the environment.
Which of the following accurately describes Florence Nightingale’s influence on nursing
knowledge?
A)
She defined nursing practice as the continuation of medical practice.
B)
She differentiated between health nursing and illness nursing.
C)
She established training for nurses under the direction of the medical profession.
D)
She established a theoretical base for nursing that originated outside the profession.
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Nightingale influenced nursing knowledge and practice by demonstrating efficient
and knowledgeable nursing care, defining nursing practice as separate and distinct
from medical practice, and differentiating between health nursing and illness nursing.
12.
During the first half of the 20th century, a change in the structure of society resulted in
changed roles for women and, in
turn, for nursing. What was one of these changes?
A)
More women retired from the workforce to raise families.
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B)
Women became more dependent and sought higher education.
C)
The focus of nursing changed to “hands-on training.”
D)
Nursing research was conducted and published.
Ans: D
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As a result of World Wars I and II, women increasingly entered the workforce,
became more independent, and sought higher education. At the same time, nursing
began to focus more on education than hands-on training, and nursing research was
conducted and published.
A staff nurse asks a student, “Why in the world are you studying nursing theory?” How would
the student best respond?
A)
“Our school requires we take it before we can graduate.”
B)
“We do it so we know more than your generation did.”
C)
“I think it explains how we should collaborate with others.”
D)
“It helps explain how nursing is different from medicine.”
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13.
Ans: D
Feedback:
Nursing theory differentiates nursing from other disciplines and activities in that it
serves the purpose of describing, explaining, predicting, and controlling desired
outcomes of nursing care practices.
14.
Why are the developmental theories important to nursing practice?
A)
They describe how parts work together as a system.
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B)
They outline the process of human growth and development.
C)
They define human adaptation to others and to the environment.
D)
They explain the importance of legal and ethical care.
Ans: B
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Developmental theories outline the process of growth and development of humans as
orderly and predictable, beginning with conception and ending with death. Nurses
apply this knowledge to develop interventions for people across the life span.
Systems theory, adaptation theories, and legal/ethical care are also important to
nursing, but these do not explain the importance of human growth and development
in nursing care.
There are four concepts common in all nursing theories. Which one of the four concepts is the
focus of nursing?
A)
Person
B)
Environment
C)
Health
D)
Nursing
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15.
Ans: A
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The four concepts listed are all common in nursing theory, but the most important—
and the focus of nursing—is the person (client).
What is the ultimate goal of expanding nursing knowledge through nursing research?
A)
Learn improved ways to promote and maintain health.
B)
Develop technology to provide hands-on nursing care.
C)
Apply knowledge to become independent practitioners.
D)
Become full-fledged partners with other care providers.
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The ultimate goal of expanding nursing’s body of knowledge through nursing
research is to learn improved ways to promote and maintain health. Ongoing
practice-based research reflects the nursing profession’s commitment to meet the
ever-changing demands of health care consumers. While doing research also
facilitates the development of technology, helps produce independent practitioners,
and provides partnerships with other providers of care, those are not the ultimate
goals of nursing research.
17.
What was significant about the promotion of the National Center for Nursing Research to the
current National Institute
of Nursing Research (NINR)?
A)
Increased numbers of articles are published in research journals.
B)
NINR gained equal status with all other National Institutes of Health.
C)
NINR became the major research body of the International Council of Nurses.
D)
It decreased emphasis on clinical research as an important area for nursing.
Ans: B
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Feedback:
The National Center for Nursing Research was promoted to the National Institute of
Nursing Research (NINR) in 1993, gaining equal status with all other National
Institutes of Health.
Which of the following is a responsibility of an institutional review board (IRB)?
A)
Secure informed consent for researchers
B)
Review written accuracy of research proposals
C)
Determine risk status of all studies
D)
Secure funding for institutional research
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Federal regulations require that institutions receiving federal funding, or conducting
studies of drugs or medical devices regulated by the Food and Drug Administration
establish IRBs. The IRB reviews all studies conducted in the institution to determine
risk status and to ensure that ethical principles are followed. The IRB does not secure
informed consent, review the accuracy of proposals, or secure funding.
19.
Before developing a procedure, a nurse reviews all current research-based literature on
insertion of a nasogastric tube.
What type of nursing will be practiced based on this review?
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A)
Institutional practice
B)
Authoritative nursing
C)
Evidence-based nursing
D)
Factual-based nursing
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Evidence-based nursing practice (EBNP) is the conscientious, explicit, and judicious
use of research-based information in making decisions about the delivery of care.
EBNP does not include institutional practice, authoritative nursing, or factual-based
nursing.
A)
P = population
B)
I = institution
C)
C = compromise
D)
O = output
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20.
One step in implementing evidence-based practice is to ask a question about a clinical
area of interest or an intervention. The most common method is the PICO format.
Which of the following accurately defines the letters in the PICO
acronym?
Ans: A
Feedback:
P = patient, population, or problem of interest, I = intervention of interest, C =
comparison of interest, and O = outcome of interest
The nurse understands that general systems theory has important implications in nursing.
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Which of the following is an
assumption of the general systems theory?
A)
Human systems are open and dynamic.
B)
All humans are born with instinctive needs.
C)
Human needs are motivational forces.
D)
People grow and change throughout their lives.
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General systems theory assumes that human systems are open and dynamic with
implicit boundaries. Human needs theory assumes that all humans are born with
instinctive needs and human needs are motivational forces. Change theory assumes
that people grow and change throughout their lives.
A)
The Internet should be the last resort for scientific literature review.
B)
Very few nursing sites are available through the Internet.
C)
Most websites that provide nursing information are reliable.
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22.
A nursing student is conducting a literature review via the Internet to identify a
problem area that may be applicable in scope for nursing. When conducting the
search, which of the following would be most important for the student to keep
in mind?
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D)
MedLine is a reputable online database of nursing information.
Ans: D
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MedLine is a highly reputable online database of nursing information. The Internet is
continuously growing as a resource for nursing research and has developed into a
sophisticated tool for information retrieval, as well as research for the general public
and for nursing and health professionals. Hundreds of sites are available through the
World Wide Web. However, not all websites that provide nursing information are
reliable.
A)
It emphasizes personal experience over science.
B)
Clinical expertise is integrated with external evidence.
C)
It involves gaining solutions to problems.
D)
The purpose is to learn about a specific problem.
Ans: B
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23.
A group of students is reviewing information about evidence-based practice in
preparation for an exam. The students demonstrate understanding of the information
when they identify which of the following as associated with evidencebased practice?
Feedback:
Evidence-based practice (EBP) is an approach to health care that realizes that
pathophysiologic reasoning and personal experience are necessary, but not sufficient
for making decisions. Advocates argue that medical decisions should be based, as
much as possible, on a firm foundation of high-grade scientific evidence, rather than
on experience or opinion. Its practice involves integrating individual clinical
expertise with the best available external evidence from systematic research. Nursing
research aims to gain solutions to problems, learn about a specific problem, or to
understand a situation.
A nurse researcher decides to conduct a qualitative research study. With which of the
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following would the researcher be
involved?
A)
Collection of numerical data
B)
Determination of cause and effect
C)
Controlling personal biases
D)
Real world data collection
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Qualitative research strives for an understanding of the whole and requires the
researcher to become the instrument as data is collected in the real-world, naturalistic
setting. Numerical data, cause and effect and control of personal bias are key aspects
of quantitative research.
In what way can a nurse differentiate strong research from poor research?
A)
By conducting the research
B)
Through author dialogue
C)
By critiquing the study
D)
Through the nurse’s own informal investigation
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Ans: C
Feedback:
Nurses must have a working knowledge of research methods, and a beginning ability
to read for application and to critique research.
Nursing research is linked most closely to what?
A)
Propositions
B)
Outcome measures
C)
Treatments
D)
Nursing process
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Many similarities are found between the formalized research process and the nursing
process format that is an integral part of nursing education.
27.
Which of the following research studies would be of most interest to a nurse manager?
A)
Sister Callista Roy’s theory on adaptation
B)
Patricia Benner’s From Novice to Expert
C)
Kleinpell and Ferrans’ older intensive-care clients
D)
Madeleine Leininger’s transcultural nursing theory
Ans: B
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Feedback:
Research affects the clinical practice of nurses in all areas, particularly in relation to
the goals of nursing. Benner’s research will assist a nurse manager to support all
levels of his or her staff.
How are the first stages of the nursing process and nursing research linked?
A)
They will answer a posed question.
B)
Each begins with goal development.
C)
The nurse assesses problems initially.
D)
There is a period of evaluation.
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The first step for the practicing nurse is to assess a problem; for the researcher, the
first step is to recognize the general problem area.
A)
Nursing student
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29.
A nursing instructor would like to study the effect peer tutoring has on student success. What
is the independent
variable?
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B)
Nursing education
C)
Peer tutoring
D)
Student success
Ans: C
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The independent variable is the presumed cause or influence on the dependent variable.
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30.
A nursing student has been asked to correlate her clinical experiences with two different
theories of nursing. The student
will recognize that which of the following concepts are common to all theories of nursing?
Select all that apply.
The client
B)
The environment
C)
Illness
D)
Needs
E)
Nursing
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A)
Ans: A, B, E
Feedback:
While nursing theories vary significantly in their conceptualizations, the elements that
are common to all include the client (person), the environment, health, and nursing.
The concepts of needs and illness are addressed by some theories but these are not
explicitly defined by other theories.
31.
Which of the following are examples of characteristics of evidence-based practice? Select all
that apply.
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It is a problem-solving approach.
B)
It uses the best evidence available.
C)
It is generally accepted in clinical practice.
D)
It is based on current institutional protocols.
E)
It blends the science and art of nursing.
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Evidence-based nursing is a problem-solving approach to making clinical decisions,
using the best evidence available. EBP may meet resistance in clinical practice as a
result of the nursing shortage, the acuity level of clients, nurse’s skill in reading and
evaluating published research, and an organizational culture that does not support
change. EBP blends both the science and the art of nursing so that the best client
outcomes are achieved. EBP takes into consideration client preferences and values
as well as the clinical experiences of the nurse.
Which of the following are characteristics of nursing theories? Select all that apply.
A)
They provide rational reasons for nursing interventions.
B)
They are based on descriptions of what nursing should be.
C)
They provide a knowledge base for appropriate nursing responses.
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D)
They provide a base for discussion of nursing issues.
E)
They help resolve current nursing issues and establish trends.
Ans: A, C, D, E
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Nursing theory provides rational and knowledgeable reasons for nursing
interventions, based on descriptions of what nursing is and what nurses do.
Additionally, nursing theory gives nurses the knowledge base necessary for acting
and responding appropriately in various situations. It also provides a base for
discussion, and, ideally, helps resolve current nursing issues. Nursing theories should
be simple and general; simple terminology and broadly applicable concepts ensure
their usefulness in a wide variety of nursing practice situations.
Which of the following examples represents the type of knowledge known as process? Select
all that apply.
A)
A nurse dispenses medications to clients.
B)
A nurse changes the linens on a client’s bed.
C)
A nurse studies a nursing journal article on infection control.
D)
A nurse consults an ethics committee regarding an ethical dilemma.
E)
A nurse believes in providing culturally competent nursing care.
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Ans: A, B
Feedback:
A process is a series of actions, changes, or functions intended to bring about a
desired result. During a process, one takes systematic and continuous steps to meet a
goal and uses both assessments and feedback to direct actions that meet the goal.
Reading a nursing journal is considered science. Consulting an ethics committee and
providing culturally competent nursing care is considered philosophy.
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A)
Historical
B)
Ethnography
C)
Grounded theory
D)
Phenomenology
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34.
Which qualitative research method is described as follows: to describe experiences as they are
lived by the subjects
being studied?
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Ans: D
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The purpose of phenomenology, which is both a philosophy and a research method, is
to describe experiences as they are lived by the subjects being studied. Historical
research examines events of the past to increase understanding of the nursing
profession today. Ethnography is used to examine issues of a culture that are of
interest to nursing. The basis of grounded theory methodology is the discovery of
how people describe their own reality, and how their beliefs are related to their
actions in a social scene.
A)
Clients must grant informed consent if they are to participate.
B)
All interventions must benefit all clients.
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The nurse working in research correctly identifies which of the following to be mandatory for
the ethical conduction of
research in a hospital setting?
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C)
The client must directly and personally benefit from the research.
D) Descriptive studies are more ethical than experimental studies.
Ans: A
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Informed consent is an absolute prerequisite for clients who are asked to participate
as subjects in a research study. Not all interventions will benefit all (or even any)
clients. The risks and benefits of research are considered carefully in light of ethical
principles, but this does not necessarily mean that every participant in a study stands
to benefit from it. Ethical standards are applicable and achievable in every type of
research, and descriptive studies are not necessarily more ethical than experiments.
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Chapter 3, Health, Wellness, and Health Disparities
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1.
The nurse is preparing a care plan for an African American man age 68 years who was
recently diagnosed with
hypertension. Age, race, gender, and genetic inheritance are examples of what human
dimension?
Physical
B)
Emotional
C)
Environmental
D)
Sociocultural
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A)
Feedback:
The physical dimension includes genetic inheritance, age, developmental level, race,
and gender. These components strongly influence a person’s health status and health
practices. The emotional dimension focuses on how the mind affects body function
and responds to body conditions. The environmental dimension includes influences
such as housing, sanitation, climate, and pollution of food, air, and water.
Sociocultural dimensions are health practices and beliefs strongly influenced by
economic status, lifestyle, family, and culture.
The mother of a toddler with asthma seeks support from the parents of other children with
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The client must directly and personally benefit from the research.
2.
asthma. The nurse recognizes
that seeking and utilizing support systems is an example of which human dimension?
A)
Sociocultural dimension
B)
Physical dimension
C)
Environmental dimension
D)
Intellectual and spiritual dimension
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C)
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Ans: A
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Communicating with others and the use of support systems relate to the sociocultural
dimension. An individual’s relationship with others, being connected to a
community, and feeling accepted and loved by others are also related to the
sociocultural dimension.
A)
Health-Illness Continuum
B)
Agent-Host-Environment Model
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3.
A nurse educator uses models of health and illness when teaching. Which model of health and
illness places high-level
health and death on opposite ends of a graduated scale?
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C)
Health Belief Model
D) Health Promotion Model
Ans: A
Feedback:
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The Health-Illness Continuum views health as a constantly changing state, with highlevel wellness and death being on opposite ends of a graduated scale. The AgentHost-Environment Model is useful in examining the causes of disease in an
individual. The Health Belief Model describes health behaviors. The Health
Promotion Model incorporates individual characteristics and experiences, as well as
behavior-specific knowledge and beliefs, to motivate healthy behavior.
A)
Bipolar disorder
B)
Pneumonia
C)
Cellulitis
D)
Tuberculosis
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4.
A homeless client has been brought to the emergency department (ED) by ambulance
after being found unresponsive outside a mall. The client is known to the ED staff as
having bipolar disorder, and assessment reveals likely cellulitis on his left ankle. He
is febrile with a productive cough, and the care team suspects pneumonia. A sputum
culture for tuberculosis has been obtained and sent to the laboratory. Which of the
following aspects of the client’s medical
condition would be considered a chronic condition?
Ans: A
Feedback:
Bipolar disorder is a long-standing diagnosis that requires the lifelong education and
treatment associated with chronic conditions. Pneumonia, tuberculosis, and cellulitis
are all acute, infectious diseases that may be treated with antibiotic regimens of
varying length.
Which of the following activities related to respiratory health is an example of tertiary health
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Health Belief Model
5.
promotion and illness
prevention?
A)
Administering a nebulized bronchodilator to a client who is short of breath
B)
Assisting with lung function testing of a client to help determine a diagnosis
C)
Teaching a client that “light” cigarettes do not prevent lung disease
D)
Advocating politically for more explicit warning labels on cigarette packages
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C)
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The use of medications is characteristic of tertiary health promotion and illness
prevention. Testing and screening are examples of secondary health promotion and
illness prevention, while client education and political advocacy are associated with
primary prevention.
A)
The Agent-Host-Environment Model
B)
The Health-Illness Continuum
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6.
An elderly resident of a long-term care facility has developed diarrhea and dehydration as a
result of exposure
to clostridium difficile during a recent outbreak. The resident’s primary care provider
has consequently prescribed the antibiotic metronidazole (Flagyl). Which model of
health promotion and illness prevention is most clearly evident in
these events?
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C)
The Health Promotion Model
D) The Health Belief Model
Ans: A
Feedback:
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The presence of an infectious microorganism and the act of treating that agent are
associated with the Agent-Host- Environment Model of health promotion and illness
prevention. The client’s beliefs about health are not central in this scenario, and
health promotion and the pursuit of health are not the most important priorities during
this active treatment of illness. This client is not being characterized as existing on a
point on a health continuum.
A)
Despite the loss of his limb, the client may consider himself to be healthy.
B)
The client may be well, but his loss of limb means that he is unhealthy.
C)
The loss of his limb prevents the client from achieving wellness, though he may be healthy.
D)
Because the client’s injury is far in the past, it does not have a bearing on his health or
wellness.
Ans: A
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7.
The nurse is performing a routine assessment of a male client who has an artificial arm as a
result of a small plane crash
many years earlier. How should the nurse best understand this client’s health?
Feedback:
Individuals who live with chronic conditions, such as the loss of a limb, may
accommodate their condition fully and consider themselves to be healthy and well.
This is not a certainty, however, and the passage of time does not guarantee such
acceptance.
8.
What phrase best describes health?
A)
Individually defined by each person
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C)
The Health Promotion Model
B)
Experienced by each person in exactly the same way
C)
The opposite of illness
D)
The absence of disease
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Health is individually defined by each person and is affected by many factors. The
most widely accepted definition of health is that it is a state of complete physical,
mental, and social well-being—not the absence of disease or infirmity. Health is
experienced differently by each person; it is not the opposite of illness, and does not
indicate the absence of disease.
Which of the following most accurately defines “illness”?
A)
The inability to carry out normal activities of living
B)
A pathologic change in mind or body structure or function
C)
The response of a person to a disease
D)
Achieving maximum potential and
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9.
quality of life Ans: C
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Feedback:
Illness is the response of a person to a disease, an abnormal process in which one’s
level of function is changed when compared with the previous level. A disease (a
medical term) means there is a pathologic change in the structure or function of the
body or mind. Wellness is a term used to describe a person achieving maximum
potential and quality of life despite disease or illness.
Which of the following statements accurately describes the concepts of disease and illness?
A)
A disease is traditionally diagnosed and treated by a nurse.
B)
The focus of nurses is the person with an illness.
C)
A person with an illness cannot be considered healthy.
D)
Illness is a normal process that affects level of functioning.
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Ans: B
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A disease is traditionally diagnosed and treated by a physician (although nurses with
advanced educations are increasingly doing so), while nurses focus on the person
with an illness. A person may have an illness or injury but still achieves maximum
functioning and quality of life, and considers himself or herself to be healthy. Illness
is the response of the person to a disease; it is an abnormalprocess in which the
person’s level of functioning is changed when compared with a previous level.
11.
A nurse calls in to his unit to report he has the flu and will not be at work. What stage of
illness behavior is he
exhibiting?
A)
Experiencing symptoms
B)
Assuming the sick role
C)
Assuming a dependent role
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D)
Achieving recovery and rehabilitation
Ans: B
Feedback:
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When assuming the sick role, the person defines himself or herself as sick, seeks
validation from others, and gives up normal activities such as going to work.
Although the other choices are stages of illness, they are not defined by the behavior
presented.
A)
Stage 1
B)
Stage 2
C)
Stage 3
D)
Stage 4
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12.
A cleint accepts the fact that he needs bypass surgery for a blocked artery and is admitted into
the hospital. Which one of
the following stages of illness is this client experiencing?
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In Stage 3, assuming a dependent role, the patient decides to accept the diagnosis and
follow the prescribed treatment plan. The person conforms to the opinions of others,
often requires assistance in carrying out activities of dailyliving, and needs emotional
support through acceptance, approval, physical closeness, and protection.
A)
The chronic disease has been cured.
B)
Nothing further can be done in terms of treatment.
C)
Severe symptoms of the chronic illness have reappeared.
D)
The disease is present, but symptoms are not experienced.
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13.
A child age 4 years has leukemia but is now in remission. What does it mean to be in
remission when one has a chronic
illness?
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Ans: D
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Many chronic illnesses have periods of remission and exacerbation. During
remission, the disease is present but the person does not experience symptoms.
During exacerbation, the symptoms of the illness reappear.
14.
What may happen to the family when one of the family members suffers an illness?
A)
Alterations in values and religious beliefs
B)
More public displays of affection
C)
Changes in roles for the client and family
D)
Increased resistance to stress
Ans: C
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When an illness occurs, roles change for both the client and the family. Chronic
illnesses often result in increased stress for the family, but responses by all members
are individualized.
A)
Physical
B)
Emotional
C)
Environmental
D)
Sociocultural
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15.
A baby is born with Down syndrome, which influences his health–illness status. This is an
example of which of the
following human dimensions?
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Ans: A
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The physical dimension includes genetic inheritance, age, developmental level, race,
and gender. These components strongly influence the person’s health status and
health practices.
16.
Which of the following statements illustrates the effect of the sociocultural dimension on
health and illness?
A)
“Why shouldn’t I drink and drive? Everyone else does.”
B)
“My mother has sickle cell anemia, and so do I.”
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C)
“I know I have heart problems, so I have changed my diet.”
D)
“I used biofeedback to lower my blood pressure.”
Ans: A
Feedback:
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Health practices and beliefs are strongly influenced by one’s sociocultural dimension,
including lifestyle, family, and culture. These factors are involved in patterns of
living (such as drinking and driving) and values about health and illness. Sickle cell
anemia involves the physical dimension; changing one’s diet involves the intellectual
dimension; and biofeedback involves the emotional dimension.
A)
“I am just too busy with my kids to bother about a diet.”
B)
“Why should I lose weight? I’ll still be fat.”
C)
“My sister is thin, but I don’t think she looks that good.”
D)
“My husband loves me this way.”
Ans: B
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17.
A middle-aged woman is 40 pounds over her ideal weight. Which of the following statements
best illustrates the effect
of her self-concept on health and illness?
Feedback:
Self-concept is an important variable affecting health and illness. People who are
overweight may believe that nothing can change the way they look and refuse to
follow a diet and exercise program.
18.
A camp nurse is teaching a group of adolescent girls about the importance of monthly breast
self-examination. What
level of preventive care does this activity represent?
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A)
Primary
B)
Secondary
C)
Tertiary
D)
Restorative
Ans: A
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Primary preventive care activities are directed toward promoting health and
preventing the development of disease. Teaching breast self-examination is an
example of a primary preventive care activity.
A)
The health promotion model
B)
The health belief model
C)
The health–illness continuum
D)
The agent–host–environment model
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19.
Which of the following models of health promotion and illness prevention was developed to
illustrate how people
interact with their environment as they pursue health?
Ans: A
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The health promotion model (Pender, Murdaugh, & Parsons, 2006) was developed to
illustrate how people interact with their environment as they pursue health. The
model incorporates individual characteristics and experiences and behavior-specific
knowledge and beliefs, to motivate healthy behavior.
A)
Physical health
B)
Emotional health
C)
Social health
D)
Spiritual health
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20.
A nurse is caring for a client who is in the remission state of leukemia. The client
expresses anxiety about the recurrence of leukemia. The client feels depressed when
thinking about the outcome of leukemia. Which aspect of health is the
client talking about?
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Anxiety and depression are components of emotional health. The client is not feeling
emotionally well because of worry about the disease outcomes. Currently the client is
in remission and thus is physically healthy. The client does not mention anything
about social interactions and spiritual health.
21.
A nurse is educating women on the need for calcium to prevent bone loss. What level of
prevention does this represent?
A)
Primary prevention
B)
Secondary prevention
C)
Tertiary prevention
D)
Residual prevention
Ans: A
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Feedback:
Primary prevention or primary health care involves the education of clients in the prevention
of disease.
A)
Age
B)
Gender
C)
Peer influence
D)
Illness factors
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22.
A client states, “I must be in poor health because I am a senior citizen. That’s what my
neighbor says and she is older
than I am.” This statement is based on which of the following factors?
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Peer influence, personality characteristics, ethnicity, and socioeconomic factors may
affect a person’s response to illness.
23.
An woman 80 years of age has had a cerebrovascular accident. She has flaccidity of her right
side with aphasia. For this
client, which of the following activities constitutes tertiary prevention?
A)
Assessment of her blood pressure
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B)
Daily bleeding and clotting times
C)
Gait training and speech therapy
D)
Education on the symptoms of a CVA
Ans: C
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Tertiary prevention occurs when a person already has been diagnosed with a long-term disease
or disability.
A)
Risk factors are unrelated to the person or event.
B)
All risk factors are modifiable.
C)
An increase in risk factors increases the possibility of illness.
D)
A family history of breast cancer is not a modifiable risk factor.
E)
School-aged children are at high risk for communicable diseases.
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24.
Which of the following statements accurately describes how risk factors may increase a
person’s chances for illness or
injury? Select all that apply.
Ans: C, D, E
Feedback:
A risk factor is something that increases a person’s chances for illness or injury. Like
other components of health and illness, risk factors are often interrelated. Risk factors
may be further defined as modifiable (able to be changed, such as quitting smoking)
or nonmodifiable (unable to be changed, such as a family history of cancer). As the
number of risk factors increases, so does the possibility of illness. School-aged
children are at high risk for communicable diseases.
Multiple sexual relationships increase the risk for sexually transmitted diseases (e.g.,
gonorrhea or acquired immunodeficiency syndrome AIDS).
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A)
They help health care providers understand health-related behaviors.
B)
They are useful for adapting care to people from diverse backgrounds.
C)
They help overcome barriers related to increased number of people without health care.
D)
They overcome barriers to care for the predicted downward trend in minority populations.
E)
They overcome barriers to care for low-income and rural populations.
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25.
Which of the following statements explains why models of health promotion and illness
prevention are useful when
planning health care? Select all that apply.
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Models of why and how individuals carry out behaviors to promote health and
prevent illness are useful in helping health care providers understand health-related
behaviors, and adapt care to people from diverse economic and cultural
backgrounds. This knowledge can be used to overcome barriers to health from
disparities in care resulting from such factors as the increasing number of people
without health insurance; a predicted upward trend in minority populations; and a
lack of accessible and essential health care services for low-income and rural
populations. Many people do not take advantage of low-cost screens and health care
information.
26.
On which of the following components is Rosenstock’s health belief model based? Select all
that apply.
A)
Perceived susceptibility to a disease
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B)
Perceived consequences of treating disease
C)
Perceived seriousness of a disease
D)
Perceived benefits of action
E)
Perceived immunity to disease
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The health belief model (Rosenstock, 1974) is concerned with what people perceive,
or believe, to be true about themselves in relation to their health. This model is based
on three components of individual perceptions of threat of a disease: (1) perceived
susceptibility to a disease, (2) perceived seriousness of a disease, and (3) perceived
benefits of action.
A)
A nurse counsels a teenager to stop smoking.
B)
A nurse conducts a health fair for high blood pressure screening.
C)
A nurse counsels the family of a client diagnosed with lung cancer.
D)
A home health care nurse arranges for rehabilitation services for a patient.
E)
A school nurse arranges for a career seminar for graduating seniors.
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27.
Which of the following nursing interventions is an example of health promotion and
preventive care on the primary
level? Select all that apply.
Ans: A
Feedback:
Primary health promotion and illness prevention are directed toward promoting health
and preventing the development of disease processes or injury. Nursing activities at
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the primary level may focus on individuals or groups. Examples are immunization
clinics, family planning services, providing poison-control information, counseling
about obesity and smoking cessation, and accident-prevention education. Conducting
a high blood pressure screening and providing family counseling are secondary level
preventive measures. Rehabilitation and career counseling fall under the tertiary level
of preventive care.
A)
Demonstrating an injection technique to a client for anticoagulant therapy
B)
Explaining the side effects of a medication to an adult client
C)
Discussing the importance of preventing sexually transmitted disease to a group of 12th-grade
students
D)
Instructing an adolescent client about safe food preparation
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28.
The nursing instructor has given an assignment to a group of nurse practitioner
students. They are to break into groups of four and complete a health-promotion
teaching project, then present a report back to their fellow students. What
project is the best example of health-promotion teaching?
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Health promotion encourages people to live a healthy lifestyle and to achieve a high
level of wellness. Discussing the importance of STD prevention to a group of 12thgrade students is the best example of a health-promotion teaching project. This makes
the other options incorrect.
29.
A nurse is providing an educational event to a local group of disabled citizens. What would be
important for the nurse to
be aware of when planning this event?
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A)
The health promotion needs of the group the nurse is speaking to
B)
What the disability of each person is
C)
Wellness needs of each individual person
D)
What the families want you to talk about
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The nurse must be aware of the health promotion needs when teaching specific
groups of people. The other options are incorrect because the nurse doesn ‘t need to
aware of them when planning the event.
A)
Gender
B)
Age
C)
Environment
D)
Lifestyle
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30.
Which of the following is not one of the six general types of risk factors in regard to
increasing an individual ‘s chances
for illness and injury?
Ans: A
Feedback:
The six general types of risk factors are age, genetics, physiologic factors, health
habits, lifestyle, and environment. Gender is not a risk factor per se, but certain
conditions, such as pregnancy, can contribute to risk.
After teaching the students about health and wellness, the nursing instructor identifies a need
for further instruction
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31.
when one of the students makes which of the following statements?
A)
“Health is more than just the absence of illness.”
B)
“Health is an active process.”
C)
“Health means the same to every person.”
D)
“Health is dynamic and ever-changing.”
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Ans: C
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Health is more than just the absence of illness; it is an active process in which a
person moves toward his or her maximum potential. It also has different definitions
for different people. It is not stagnant, but changes frequently.
A)
Acute
B)
Chronic
C)
Terminal
D)
Contagious
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32.
A client is admitted to the hospital with abrupt symptoms of increasing shortness of
breath, fever, and a productive cough with green sputum. Upon further exam the
client is diagnosed with chronic obstructive pulmonary disease
(COPD) exacerbation. The nurse identifies this as which type of illness?
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Ans: B
Feedback:
Chronic illness encompasses many different physical and mental alterations in health.
Chronic illnesses usually have a slow onset and many periods of remission (disease is
present, but there are no symptoms) and exacerbation (symptoms of the disease
reappear). COPD is not terminal (although there is no cure) and it is not contagious.
A)
Primary health promotion
B)
Secondary health promotion
C)
Tertiary health promotion
D)
Chronic health promotion
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33.
A nurse is giving a talk to a local community group on the importance of proper diet and
regular exercise. This is an
example of which type of health promotion?
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Ans: A
Primary health promotion is aimed at promoting health and preventing the
development of a disease. Examples of primary promotion are immunizations, family
planning, the teaching of healthy diet, regular exercise, safety, and safe sex.
Secondary health promotion is aimed at early detection of the disease and treatment.
Tertiary promotion begins after the disease is diagnosed and treated, with the goal of
reducing disability and helping in rehab. The term chronic is not related to health
promotion.
34.
An older adult male client is admitted to the cardiac ICU after suffering a heart
attack. Upon taking a history after the client is stable, the nurse charts that he weighs
over 275 pounds, has a history of heart disease in his family, suffers frequent stress at
work, drinks alcohol daily, and smokes two packs of cigarettes daily. What are some
modifiable risks
factors for this client that has attributed to his heart attack? Select all that apply.
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Alcohol intake
B)
Smoking
C)
Stress
D)
Age
E)
Family history
F)
Sex
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A)
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The modifiable risk factors related to this client’s heart attack include stress, alcohol
intake, and smoking. These are things that a person can change. The others are
nonmodifiable, as the client cannot change his age, family history, or sex.
A)
Immunization clinics
B)
Poison control information
C)
Screenings for blood pressure
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35.
A nurse is giving a talk to a local community group on health promotion and illness
prevention. The nurse explains the different levels of promotion. Which of the
following does the nurse include when talking about primary promotion?
Select all that apply.
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D)
Recommending mammograms for women
E)
Teaching about a healthy diet
Ans: A, B, E
Feedback:
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Primary health promotion is directed toward promoting good health and preventing
disease. Examples include immunization clinics, providing poison control
information, and accident prevention. Teaching about a healthy diet, regular exercise,
and using seat belts are other examples. Secondary health promotion focuses on
screening for early detection of diseases with prompt diagnosis. Things included are
screenings for blood pressure and cholesterol, recommending gynecologic exams, and
recommending mammograms for women at appropriate ages.
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Chapter 4, Health of the Individual, Family, Community and Environment
Physiologic
C)
Self-esteem
D)
Self-actualization
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Love and belonging
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A)
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The nurse who is caring for a child admitted after an automobile accident recognizes the
importance of including the
child’s family in the plan of care. Inclusion of the family meets which of Maslow’s basic
human needs?
Ans: A
Feedback:
Love and belonging needs include the understanding and acceptance of others in both
giving and receiving love, and the feeling of belonging to families, peers, friends, a
neighborhood, and a community. The inclusion of family and friends in the care of a
client is a nursing intervention to meet this need.
The community health nurse is creating a plan of care for a client with Parkinson’s
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A)
Risk for Caregiver Role Strain.
B)
Health Seeking Behaviors.
C)
Parental Role Conflict.
D)
Readiness for Enhanced Family Processes.
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2.
disease. The client’s spouse has provided care to the client for the past five years and
the client’s care needs are increasing. What is an appropriate
nursing diagnosis for the client and family?
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Long-term care of a family member with a chronic illness may lead to caregiver role
strain, so the most appropriate nursing diagnosis is “Risk for Caregiver Role Strain.”
A)
Engage in appropriate health promotion activities.
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3.
During the course of assessing the family structure and behaviors of a pediatric
patient’s family, the nurse has identified a number of highly significant risk factors.
Which of the following actions should the nurse prioritize when addressing
these risk factors?
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B)
Validate the family’s unique way of being.
C)
Enlist the help of community and social support.
D)
Introduce the family to another family that possesses fewer risk factors.
Ans: A
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The role of the nurse in reducing risk factors involves activities that promote health
for all family members at any level of development. This consideration supersedes
the importance of validating the family’s current way of being or enlisting the help
of others. Introducing the family to a “model” family is ethically and logistically
questionable.
According to Maslow’s basic human needs hierarchy, which needs are the most basic?
A)
Physiologic
B)
Safety and security
C)
Love and belonging
D)
Self-esteem
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Ans: A
Feedback:
Physiologic needs, the most basic in the hierarchy of needs, are the most essential to
life and have the highest priority. Physiologic needs include oxygen, water, food,
temperature, elimination, sexuality, physical activity, and rest.
5.
Which of the following is a tenant of Maslow’s basic human needs hierarchy?
A)
A need that is unmet prompts a person to seek a higher level of wellness.
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B)
A person feels ambivalence when a need is successfully met.
C)
Certain needs are more basic than others and must be met first.
D)
People have many needs and should strive to meet them simultaneously.
Ans: C
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Maslow arranged the hierarchy to show that certain needs are more basic than others.
Although all people have all the needs all the time, people generally strive to meet
priority needs (at least to a minimal level) before attending to other needs. The
hierarchy is also based on the theory that something is a basic need if it has the
following characteristics:(1) its absence results in illness, (2) its presence helps
prevent illness or signals health, (3) meeting the need restoreshealth,
(4) it is preferred over other satisfactions when unmet, (5) one feels something is missing
when the need is not met, and
(6) one feels satisfaction when the need is met.
A)
Safety and security
B)
Love and belonging
C)
Self-esteem
D)
Self-actualization
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6.
An woman 80 years of age states, “I have successfully raised my family and had a good life.”
This statement illustrates
meeting which basic human need?
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Ans: D
Feedback:
The highest level on the hierarchy of basic human needs is for self-actualization,
which includes acceptance of self and others, reaching one’s full potential, and
feelings of happiness and affection for others.
A)
Giving him his favorite stuffed animal to hold
B)
Assessing respirations and administering oxygen
C)
Raising the side rails and restraining his arms
D)
Asking his mother what are his favorite foods
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7.
A boy age 2 years arrives at the emergency department of a local hospital with difficulty
breathing from an asthmatic
attack. Which of the following would be the priority nursing intervention?
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Ans: B
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The priority need for a child having respiratory difficulty is for oxygen. Therefore,
the nurse’s immediate interventions should be to meet physiologic oxygen needs by
assessing respirations and administering oxygen. Oxygen needs are more basic than
are needs for food or safety and security.
A man 75 years of age is being discharged to his home following a fall in his kitchen that
resulted in a fractured pelvis.
8.
The home health nurse makes a home assessment that will be used to design
interventions to meet which priority need?
A)
Sleep and rest
B)
Support from family members
C)
Protection from potential harm
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D)
Feeling a sense of accomplishment
Ans: C
Feedback:
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Physical safety and security means being protected from potential or actual harm.
Assessing potential risks for harm in the home environment is necessary to meet
physical safety needs. For this situation, protecting the patient from potential harm
has a higher priority than interventions that focus on sleep and rest, support from
family members, and feeling a sense of accomplishment.
A)
Physiologic
B)
Safety and security
C)
Love and belonging
D)
Self-actualization
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9.
A nurse caring for a client in a long-term health care facility measures his intake and output
and weighs him to assess
water balance. These actions help to meet which of Maslow’s hierarchy of needs?
Feedback:
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A balance between the intake and elimination of fluids is essential to life and is,
therefore, a physiologic need, according to Maslow’s hierarchy of needs. Measuring
intake and output, testing the resiliency of the skin, checking the condition of the
skin and mucous membranes, and weighing the patient all help the nurse assess water
balance.
What action by a nurse will help a client meet self-esteem needs?
A)
Verbally negate the client’s negative self-perceptions
B)
Freely give compliments to increase positive self-regard
C)
Independently establish goals to improve self-esteem
D)
Respect the client’s values and belief systems
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Self-esteem needs include the need to feel good about oneself, to feel pride and a
sense of accomplishment, and to believe others respect and appreciate those
accomplishments. By respecting the client’s values and beliefs, the nurse can meet
self-esteem needs.
11.
A nurse caring for a female client in isolation with tuberculosis is aware that the client’s love
and belonging needs may
not be properly met. Which of the following nursing actions would help to meet these needs?
A)
Respecting the patient’s values and beliefs
B)
Focusing on the client’s strengths rather than problems
C)
Using hand hygiene and sterile technique to prevent infection
D)
Encouraging family to visit and help in the care of the client
Ans: D
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Feedback:
Love and belonging needs are met by including family and friends in the care of the
client, establishing a nurse–client relationship based on mutual understanding and
trust, and referring clients to specific support groups.
Which of the following statements accurately describes how Maslow’s theory can be applied
to nursing practice?
A)
Nurses can apply this theory to the nursing process.
B)
Nurses can identify met needs as health care needs.
C)
Nurses cannot use the theory on infants or children.
D)
Nurses use the theory for ill, as opposed to healthy, patients.
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12.
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Nurses can apply Maslow’s hierarchy of basic needs in the assessment, planning,
implementation, and evaluation of patient care. The hierarchy can be used with
patients at any age, in all settings where care is provided, and in both health and
illness. It helps the nurse identify unmet needs as they become health care needs.
13.
A couple recently married. Both the husband and the wife have previously been married and
had two children. What
name is given to this type of family?
A)
Extended family
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B)
Nuclear family
C)
Blended family
D)
Cohabiting family
Ans: C
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The blended family is one that is formed when parents bring unrelated children from
previous relationships together to form a new family. An extended family includes
relatives; a nuclear family is the traditional father/mother/children; a cohabiting
family is composed of members who live together but are not married.
A)
Peers
B)
Family
C)
Community
D)
Health care providers
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14.
Which of the following groups involves all parts of a person’s life and is concerned with
meeting basic human needs to
promote health?
Ans: B
Feedback:
Almost every person is a member of a number of groups, such as friends, colleagues
at work, or members of a church or school class. Each of these groups involves a
specific part of the person’s life and is important to the person. Only the family,
however, is concerned with all parts of a person’s life and with meeting his or her
basic human needs to promote health.
An unmarried couple in a committed relationship live together with their adopted twin boys.
Which of the following best
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describes this type of family?
A)
Nuclear family
B)
Extended family
C)
Blended family
D)
Adoptive family
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Ans: A
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The nuclear family, also called the traditional family, is composed of two parents and
their children. The parents might be heterosexual or homosexual, are often married or
in a committed relationship, and all members of the family live in the same house until
the children leave home as young adults. The nuclear family may be composed of
biologic parents and children, adoptive parents and children, surrogate parents and
children, or stepparents and children.
A)
The nurse does not want the client to feel lonely.
B)
The client will be more compliant with medical instructions.
C)
The family will be more willing to listen to instructions.
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16.
When providing nursing care to a client, the nurse provides family-centered nursing care.
What is one rationale for this
nursing action?
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D)
Illness in one family member affects all family members.
Ans: D
Feedback:
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Family-centered nursing care is important because the family is composed of
interdependent members who affect one another. An illness in one family member
affects all other members of the family; the role of the family is essential in nursing
care; the level of health can be improved in all family members; illness in one family
member may suggest the same problem in other family members.
A mother teaches her son to respect his elders. This is an example of which of the following
family functions?
A)
Physical
B)
Economic
C)
Affective and coping
D)
Socialization
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17.
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Feedback:
Families have functions that are important in how individual family members meet
their basic human needs and maintain their health. Through socialization, the family
teaches; transmits beliefs, values, attitudes, and coping mechanisms; provides
feedback; and guides problem solving (Friedman, Bowden, & Jones, 2003).
18.
What is the purpose of the affective and coping function of the family?
A)
Providing a safe environment for growth and development
B)
Ensuring financial assistance for family members
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C)
Providing emotional comfort and identity
D)
Transmitting values, attitudes, and beliefs
Ans: C
Feedback:
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The affective and coping function of the family is necessary to provide emotional
comfort to family members and to help members establish an identity to be
maintained in times of stress. The physical function provides a safe environment for
growth and development, the economic function ensures financial assistance, and the
socialization function transmits values, attitudes, and beliefs.
A)
Establish a mutually satisfying marriage.
B)
Adjust to cost of family life.
C)
Maintain supportive home base.
D)
Maintain ties with younger and older generations.
Ans: C
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19.
A nurse provides health promotion and accident prevention programs for a family with
adolescents and young adults.
Which of the following is a task of a family at this stage?
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Families at this stage must maintain open communication, support moral and ethical
family values, balance teenagers’ freedom with responsibility, maintain supportive
home bases, and strengthen marital relationships.
Which of the following individuals would the nurse assess as being most at risk for altered
family health?
A)
An unmarried adolescent with a newborn
B)
A newly married couple who ask about birth control
C)
A middle-aged man and woman with no children
D)
An older adult, living in an assisted-living community
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20.
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It is important for the nurse to assess a client’s family for family risk factors that may
cause health problems. A developmental risk factor for family health is an unmarried
adolescent mother who lacks personal, economic, and educational resources.
What is the major effect of a health crisis on family structure?
A)
Adaptation to stress
B)
Change in roles of family members
C)
Respect for family values
D)
Loss of individual identities
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21.
Ans: B
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Illness may precipitate a health crisis in a family. Serious illness or injury may result
in changes in family roles, responsibilities, and functions. Regardless of how the
family adapts to an illness, members of the family must constantly adjust roles and
responsibilities to manage the needs of the ill family member.
Which of the following statements accurately describes a characteristic of a community?
A)
Communities do not exist in rural areas.
B)
Communities are formed by the characteristics of people and other factors.
C)
Communities are not limited by geographic boundaries.
D)
Communities have little or no effect of the health of residents.
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22.
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A community is a specific population or group of people living in the same
geographic area under similar regulations and having common values, interests, and
needs. A community may be a small neighborhood in a major urban city or a large
rural area encompassing a small town. Communities are formed by the
characteristics of people, area, social interaction, and common familial, cultural, or
ethnic heritage and ties. Within a community, people interact and share resources.
Many community factors affect the health of residents.
23.
Which of the following is an example of a community factor that may affect health?
A)
Rural setting
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B)
Air and water quality
C)
Number of residents
D)
Educational level
Ans: B
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The health of a community is affected by the social support systems, the community
health structure, environmental factors, and types of agencies providing assistance
for those in need of shelter, housing, and food. Air pollution and water pollution are
community risk factors that may affect health. Living in a rural setting, the number
of residents, and/or educational level are not factors in the community that are
considered to affect health.
Which of the following factors may be a barrier to health care services for those living in rural
areas?
A)
Inadequate health care insurance
B)
Lack of knowledge about needed care
C)
Living long distances from services
D)
Decreased interest in health promotion
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24.
Ans: C
Feedback:
The size and location of a community often determines the size and availability of
health care services. Although urban residents have various means of transportation
to a variety of health care services, rural residents may have to travel long distances
for care. Rural residents do not necessarily have inadequate health care insurance,
lack knowledge of needed care, or have decreased interest in health promotion.
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25.
Which of the following definitions best describes community-based nursing?
A)
A focus on populations within the community
B)
A focus on older adults living in nursing homes
C)
Care provided in the client’s home for chronic illnesses
D)
care centered on individual and family health care needs
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In contrast to community health nursing, which focuses on populations within a
community, community-based nursing is centered on individual and family health
care needs. Interventions are designed to manage health problems, promote good
health, and facilitate self-care. Public health nursing focuses on populations.
What is one method by which a nurse can be a role model to promote health in the
community?
A)
Demonstrating a healthy lifestyle
B)
Becoming a member of a family
C)
Meeting own basic needs
D)
Exhibiting self-
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26.
actualization Ans: A
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Feedback:
Nurses promote health in the community by providing health care services in a
variety of settings, by serving as volunteers in health-related activities, and by being
role models for health practices and lifestyles.
A)
Interview
B)
Physical assessment
C)
Survey
D)
Poll
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27.
A nurse assigned to a client’s care schedules a family assessment of the client. Which of the
following should the nurse
use for basic family assessment?
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The nurse should use an interview for the basic family assessment. Physical
assessment is used for individual assessment. Surveys and polls are used for
community assessment.
28.
When a family visits the counseling clinic for the first time, which of following activities will
the nurse complete as part
of the initial family assessment?
A)
Discuss the roles of the parents.
B)
Outline the basic needs of the family.
C)
Resolve all family conflicts.
D)
Interview the family members.
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Ans: D
Feedback:
At the beginning level, a basic family assessment requires observation, comparison, and
interview.
A)
Family with young children
B)
Family with adolescents and young adults
C)
Family with middle-aged adults
D)
Family with older adults
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29.
The nurse is planning interventions to promote the health of a family struggling with loss of
energy and privacy for the
parents. In which family stage is the family?
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A family with young children needs to cope with loss of energy and privacy of the
parents. A family with adolescents and young adults must balance the teenagers’
freedom with responsibility. A family with middle-aged adults strives to maintain
ties with both younger and older generations. A family with older adults may
contemplate moving from the family home they have lived in for years.
30.
The nursing student asks the nurse about the difference between family-centered nursing and
client-centered nursing.
Which of the following would be inappropriate for the nurse to include when responding to
the student?
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A)
The family is composed of interdependent members who affect one another.
B)
The health of the family can be improved through health promotion activities.
C)
A strong relationship exists between the family and the health status of its members.
D)
Illness of one family member infrequently occurs in other members.
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Ans: D
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Feedback:
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According to Friedman and associates, family-centered nursing is based on four
premises: (1) The family is composed of interdependent members who affect one
another; (2) a strong relationship exists between the family and the health status of its
members; (3) the health of the family can be improved through health promotion
activities; and (4) illness of one family member may suggest the possibility of the
same problem in other members.
The nurse is assessing the functions of a family. Which items are functions of the family?
Select all that apply.
A)
Provide a safe, comfortable home in which to reside.
B)
Communicate cultural values and beliefs to family members.
C)
Provide emotional support to family members.
D)
Secure adequate income to meet the needs of the family.
E)
Make referrals to community-based healthcare resources
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31.
Ans: A, B, C, D
Feedback:
Family functions include: (1) providing a safe, comfortable home; (2) securing
adequate income; (3) providing emotional support; and (4) communicating cultural
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values and beliefs. Nurses make referrals to community-based health care agencies to
secure resources for families in need.
A)
The community will establish an effective wastewater disposal system by January 22.
B)
The community will demonstrate pride by posting a welcome sign and flowers at the edge of
town by April 8.
C)
The community will open a senior citizens center by March 9.
D)
The community will identify a walking path through the community by February 2.
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32.
Based on a community assessment, the nurse has set the following outcomes. Which outcome
reflects Maslow’s level of
safety and security needs?
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Availability of an effective wastewater disposal system will promote the safety of the
community. Physical activity, such as availability of a walking path, is essential for
Maslow’s physiologic needs. Availability of a senior citizens center represents a
solution to feeling love and belonging for older adults. Self-esteem and pride is
demonstrated by welcome signs and flowers at the edge of town.
33.
The nursing student is assessing a community in regard to safety and security. Which of the
following would be
inappropriate for the nursing student to include under this basic need category?
A)
Parks and swimming pools
B)
Police and fire departments
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C)
Sanitation facilities
D)
Housing and zoning codes
Ans: A
Feedback:
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Police and fire departments, sanitation facilities, and housing and zoning codes
protect the safety of the members of the community. Parks and swimming pools
provide recreation for the members, meeting physiological needs.
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34.
Five functions have been identified as being essential to the growth of individuals and
families. One of these functions is
education and support. How is support manifested in the context of coping with crisis and
illness situations?
Making clear distinctions between the generations
B)
Actions that tell family members they are cared about and loved
C)
The promotion of exercise in the lifestyle
D)
Transmitting culture and acceptable behaviors
Ans: B
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A)
Feedback:
Five family functions are viewed as essential to the growth of individuals and
families. The first function, management, involves the use of power, decision making
about resources, establishment of rules, provision of finances, and future planning —
responsibilities assumed by the adults of the family. The second function, boundary
setting, makes clear distinctions between the generations and the roles of adults and
children within the family structure. The third function, communication, is important
to individual and family growth; healthy families have a full range of clear, direct,
and meaningful communication among their members. The fourth function is
education and support. Education involves modeling skills for living a physically,
emotionally, and socially healthy life. Support is manifested by actions that tell
family members they are cared about and loved; it promotes health and is seen as a
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critical factor in coping with crises and illness situations. The fifth function,
socialization, involves families’ transmission of culture and the acceptable behaviors
needed to perform adequately in the home and in the world.
A)
Toxic spill
B)
Earthquake
C)
War
D)
Terrorist event
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35.
The nurse conducting a community emergency preparedness education class includes which of
the following as an
example of a natural disaster?
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Ans: B
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A disaster is broadly defined as a tragic event of great magnitude that requires the
response of people outsidethe involved community. Disasters can be categorized
as natural (e.g., massive flooding following a hurricane or an earthquake) or manmade (e.g., a toxic spill, war, or a terrorist event).
Chapter 5, Culturally Respectful Care
1.
A nursing instructor has assigned a student to care for a client of Asian descent. The
instructor reminds the student that personal space considerations vary among cultures.
What personal space preferences are important for the student to
consider when caring for this client?
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A)
People of Asian descent prefer some distance between themselves and others.
B)
People of Asian descent commonly stand close to one another when talking.
C)
People of Asian descent touch one another when sitting next to a familiar person.
D)
People of Asian descent prefer direct eye contact when communicating.
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Ans: A
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Individuals of Asian descent are more comfortable with some distance between
themselves and others. Direct eye contact may be considered impolite or aggressive
within the Asian culture, and they may tend to avoid direct eye contact and avert their
eyes while speaking with others.
A)
Values and beliefs are often present oriented.
B)
Families are usually patriarchal.
C)
They possess weak religious affiliations.
D)
Families are highly competitive.
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2.
When providing nursing care to an African American individual, which of the following
cultural factors should the nurse
consider?
Ans: A
Feedback:
Cultural factors that should be considered when providing care to the African
American family include the recognition that the family is usually matriarchal,
values and beliefs are present oriented, there is strong family unity and cooperation,
and families are frequently highly religious and highly respect the African American
clergy.
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A)
Lactose enzyme deficiency
B)
Tuberculosis
C)
Sickle cell anemia
D)
Suicide
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3.
The nurse is obtaining a health history from a patient of Puerto Rican descent. Which of the
following is most likely to
be a health problem that has a cultural connection for this patient?
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Ans: A
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Common health problems that may affect the Puerto Rican population include
lactose enzyme deficiency and parasitic diseases. Tuberculosis is a common health
problem for the Native American population. Sickle cell anemia predominantly
affects the African American population, and suicide is a common health problem
for the Native American and white middle-class populations.
A)
Cultural blindness
B)
Stereotyping
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4.
Despite the presence of a large number of elderly residents of Asian heritage, a longterm care facility has not integrated the Asian concepts of hot and cold into meal
planning. Which of the following should the nurses at the facilityrecognize
this as an example of?
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C)
Cultural assimilation
D)
Cultural imposition
Ans: A
Feedback:
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Cultural blindness is characterized by ignoring cultural differences or considerations
and proceeding as if they do not exist. This phenomenon may underlie the failure to
incorporate cultural considerations into dietary choices. Stereotyping assumes
homogeneity of members of other cultures. Cultural assimilation involves the
replacement of values with those of a dominant culture. Cultural imposition presumes
that everyone should conform to a majority belief system.
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5.
When providing care on an Indian reservation, the nurse has prioritized assessments for
diabetes and fetal alcohol
syndrome when working with residents of the reservation. How should this nurse’s practice be
best understood?
The nurse is correct in assessing for health problems that have a higher incidence and
prevalence among this population.
B)
The nurse is stereotyping American Indians as leading unhealthy lifestyles and abusing
alcohol.
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A)
D)
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C)
The nurse is performing cultural imposition of the majority American culture, and the
accompanying beliefs around
diabetes and alcohol use.
The nurse should seek specific permission from each client before proceeding with these
assessments.
Ans: A
Feedback:
Because diabetes and fetal alcohol syndrome are known to have a higher incidence
and prevalence among American Indians, Nurse K. is justified in reflecting this
objective reality during health assessment. This action is rooted in epidemiology, not
the inaccurate generalizations of stereotyping. Because the consequences of both
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C)
Cultural assimilation
problems are significant and objective, Nurse K. is not guilty of cultural imposition
and specific permission for these assessments is not likely necessary.
A)
Cultural assimilation
B)
Cultural shock
C)
Cultural imposition
D)
Cultural
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6.
A Mexican immigrant who migrated to the United States and lives in a Spanishspeaking community with other relatives is taken to the ER following a fall at work.
He is admitted to the hospital for observation. The nurse is aware tht this
client is at risk for:
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Culture shock refers to the feelings a person experiences when placed in a different
culture perceived as strange. Culture shock may result in psychological discomfort or
disturbances, as the patterns of behavior a person found acceptable and effective in
his or her own culture may not be adequate or even acceptable in the new one. The
person may then feel foolish, fearful, incompetent, inadequate, or humiliated.
7.
A nurse walks by a client’s room and observes a Shaman performing a healing ritual
for the client. The nurse then remarks to a coworker that the ritual is a waste of time
and disruptive to the other clients on the floor. What feelings is
this nurse displaying?
A)
Culture conflict
B)
Cultural blindness
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C)
Stereotyping
D)
Cultural shock
Ans: A
Feedback:
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Culture conflict occurs when people become aware of cultural differences, feel
threatened, and respond by ridiculing the beliefs and traditions of others to make
themselves feel more secure about their own values.Cultural blindness occurs when
one ignores differences and proceeds as though they do not exist. Stereotyping is the
assumption that all members of a culture, ethnic group, or race act alike. Culture
shock refers to the feelings a person experiences when placed in a different culture
that is perceived as strange.
A)
Most people react to pain in the same way.
B)
Pain in adults in less intense than pain in children.
C)
The client has a low pain tolerance.
D)
Pain is what the client says it is.
Ans: D
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8.
A nurse is caring for a client from Taiwan who constantly requests pain medication. What
should the nurse consider
when assessing the client’s pain?
Feedback:
Pain is what the client says it is, and nursing care should always be individualized.
The nurse respects the client’s right to respond to pain in whatever manner is
culturally and individually appropriate and never stereotypes a client’s perceptions
or responses to pain. Pain tolerance is subjective; again, the client’s pain is what she
says it is.
9.
A father, mother, grandmother, and three school-aged children have immigrated to the United
States from Thailand.
Which member(s) of the family are likely to learn to speak English more rapidly?
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Stereotyping
A)
Unemployed father
B)
Stay-at-home mother
C)
Grandmother
D)
Children
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C)
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Ans: D
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When people from another part of the world move to the United States, they may
speak their own language fluently but have difficulty speaking English. This is
especially true for women, older adults, and those who are unemployed.
Children usually assimilate more rapidly and learn the language more quickly
because they go to school each day and make new friends in the dominant culture.
A)
The client is embarrassed by the questions.
B)
This is culturally appropriate behavior.
C)
The client dislikes the nurse.
D)
The client does not understand what is being asked.
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10.
A 40-year-old nurse is taking a health history from a Hispanic man aged 20 years. The nurse
notes that he looks down at
the floor when he answers questions. What should the nurse understand about this behavior?
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Ans: B
Feedback:
Eye contact is one of the most culturally variable forms of communication. Although
Americans emphasize eye contact while speaking, Hispanics look downward in
deference to age, gender, social position, economic status, and authority.
A)
The woman does not like to eat with other residents of the home.
B)
The woman is using this as a means of going home.
C)
The food served may not be culturally appropriate.
D)
The food served may violate religious beliefs.
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11.
An older adult woman of Chinese ancestry refuses to eat at the nursing home, stating, “I’m
just not hungry.” What
factors should the staff assess for this problem?
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Ans: C
Residents in long-term care settings often do not have much choice of foods. As a
result, they may not be able to select cultural food preferences. When assessing the
cause of decreased appetite in clients, the nurse should determine whether the
problem may be related to culture.
12.
All of the following are factors to consider when caring for clients with limited income. Which
one is
the most important?
A)
Basic human needs may go unmet
B)
Limited access to reliable transportation
C)
Decreased access to health care services
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D)
Risk for increased incidence of disease
Ans: A
Feedback:
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Poverty prevents many people from consistently meeting their basic human needs.
Limited means of transportation, decreased access to health care services, and an
increased incidence of disease are also influenced by limited income, but meeting
one’s basic human needs is the most important factor.
A)
We do not allow our clients to drink herbal tea.
B)
Why in the world would you want to drink that stuff?
C)
Let me check with the doctor to make sure it is okay to drink the tea with your medicines.
D)
I have to fill out a lot of forms that you will have to sign before I can do that.
Ans: C
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13.
The nurse is providing home care for a client who traditionally drinks herbal tea to treat an
illness. How should the nurse
respond to a request for the herbal tea?
Feedback:
Herbs are a common method of treatment in many cultures. If a client traditionally
drinks an herbal tea to alleviate symptoms of an illness, there is no reason why both
the herbal tea and the prescribed medications cannot be used as long as the tea is safe
to drink and does not interfere with, or exaggerate, the action of the medications.
Asking why the
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patient would want to drink “that stuff” is demeaning to the patient. Answer d is
incorrect because there is no paperwork necessary.
A)
The nurse’s knowledge and skills are not adequate to care for clients with acute illnesses.
B)
The nurse respects and values providing culturally competent care.
C)
The nurse is attempting to overcome cultural blindness.
D)
This employment makes the nurse feel superior to a minority group of people.
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14.
A nurse in a large metropolitan city enjoys working in a health clinic that primarily serves
Hispanic clients. What does
this statement imply about the nurse?
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Ans: B
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The nurse who recognizes and respects cultural diversity has cultural
sensitivity, avoids cultural imposition and ethnocentrism, and provides
nursing care that accepts the significance of cultural factors in health and
illness.
A)
Culture shock
B)
Stereotyping
C)
Cultural imposition
D)
Cultural
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15.
A nurse is providing care for a Cambodian client. The nurse says, “You have to get up and
walk whether you want to or
not.” What is this statement an example of?
competence Ans: C
Feedback:
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Cultural imposition is the tendency for health care personnel to impose their beliefs,
practices, and values on people of other cultures because they believe their ideas are
superior. When health care professionals assume they have the right to make
decisions for clients, the clients often respond by becoming passive, angry, or
resistant to treatment.
A)
The client does not want the nurse to visit.
B)
The husband does not trust his wife to answer questions.
C)
The cltient is not able to answer the questions.
D)
The husband is the dominant member of the family.
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16.
A home health nurse is visiting a client 60 years of age. During the initial visit, the client’s
husband answers all of the
questions. What would the nurse assess based on this behavior?
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Feedback:
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To provide culturally competent care, the nurse must take into consideration the role
of the family member who makes most decisions. To disregard this fact or to proceed
with nursing care that is not approved by this person can result in conflict or disregard
for what is being taught.
17.
An Asian American male client is operated on for gallstones. On the postoperative
night, the nurse finds that the client is not sleeping and is tossing and turning. When
asked about analgesics, the client expresses that he does not have pain.
What nursing action is most appropriate?
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A)
Believing that the client has no pain
B)
Assessing for non-verbal expressions of pain
C)
Inspecting the incision site for any abnormality
D)
Asking the client if he is feeling
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hungry Ans: B
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Feedback:
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The nurse should be aware that in Asian American culture, men tend to control their
emotions and expressions of physical discomfort. Keeping this in mind, the nurse
should assess the client for non-verbal expressions of pain. The nurse should not
believe the client when he says that he does not have pain because, after surgery, pain
is likely to occur. The nurse may inspect the incision site, but it is not an appropriate
action. Asking the client if he is hungry may be irrelevant.
A)
Do not probe into emotional issues.
B)
Do not ask very personal questions.
C)
Sit at the other corner of the room.
D)
Maintain eye contact while talking.
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18.
An Anglo American client reports to the primary health care facility with symptoms of fever,
cough, and running nose.
While interviewing the client, which of the following points should the nurse keep in mind?
Ans: D
Feedback:
While interviewing an Anglo-American client, the nurse should maintain eye
contact, because it indicates openness and sincerity. Anglo-Americans freely express
positive and negative feelings; therefore, the nurse may probe into emotional issues.
Anglo-American culture is an open culture, and members of this culture don’t mind
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providing personal information. Also, Anglo-Americans are not threatened by
closeness, so the nurse may not have to sit in another corner of the room.
A)
Are you having pain in your leg?
B)
Tell me what you are feeling.
C)
Do you need pain medication?
D)
Are you feeling all right?
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19.
A nurse is caring for a client after internal fixation of a compound fracture in the
tibia. The nurse finds that the client has not had his dinner, seems restless, and is
tossing on the bed. Keeping in mind that the client is Latino, what is the most
appropriate response by the nurse?
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Ans: B
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Feedback:
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The nurse should ask the client what he is feeling. Asking open-ended questions
would encourage the client to verbalize his pain. Latino men may not demonstrate
their feelings or readily discuss their symptoms because they may interpret doing so
as being less than manly. Closed-ended questions like Are you having pain?; Do you
need pain medication?; and Are you feeling all right? may block communication and
the client may not express his feelings.
20.
A client who has difficulty sleeping expresses to the nurse that watching television
may help him relax and get sleep. The nurse disregards the client’s concern and
suggests drinking warm milk before going to bed. Which cultural
characteristic is the nurse demonstrating?
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A)
Stereotype
B)
Ethnocentrism
C)
Racism
D)
Relativity
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Ans: B
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The nurse disregarding the client’s concern is an example of ethnocentrism.
Ethnocentric people view one’s own culture as the only correct standard by which to
view people of other cultures. Stereotypes are preconceived and untested beliefs
about people. Racism uses skin color as the primary indicator of social value.
Understanding that cultures relate differently to the same given situation is called
relativity.
A)
Preconceived and untested belief about people
B)
Viewing one’s own culture as the only correct standard
C)
Common and observable expressions of culture
D)
Belief system held to varying degrees as absolute
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21.
A nurse engages in professional rituals as a means to standardize practice and ensure
efficiency. In doing so, the nurse
integrates understanding of which of the following as a characteristic?
truth Ans: C
Feedback:
Rituals are common and observable expressions of culture. A preconceived and
untested belief about people is called a stereotype. Viewing one’s own culture as the
only correct standard is ethnocentrism. A belief system held to varying degrees as
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absolute truth is referred to as culture.
Anxiety
B)
Disparity
C)
Resolution
D)
Shock
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22.
The client in a rehabilitation unit is having a difficult time adjusting to the scheduled activities
on the unit, as well as
being dependent on others for meals and medications. Which word best describes what the
patient is experiencing?
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Ans: D
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The acute experience of not comprehending the culture in which one is situated is
called culture shock. This is often experienced by a client who suddenly finds himself
or herself in the subculture of a hospital or health care agency.
A)
Family
B)
Physician
C)
Tribal medicine man
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23.
A nurse in the hospital is caring for a Native American male. What person is most important to
include in the care of the
client?
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D)
Physical therapy aide
Ans: C
Feedback:
Observance of rituals in times of stress and uncertainty helps to restore a sense of
control, competence, and familiarity; to that extent, these rituals are a desirable
adjunct to nursing care.
A)
Stigma
B)
Ethnic slur
C)
Bias
D)
Stereotype
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24.
When a labor and delivery nurse tells a coworker that an Asian client probably did not want
any pain medication
because “Asian women typically are stoic,” the nurse is expressing a belief known as what?
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Ans: D
Feedback:
Stereotypes are preconceived and untested beliefs about people. Ethnic slur refers to a
statement made about another according to their ethnicity; stigma refers to social
disapproval; bias refers to an inability to view someone or something without being
objective.
25.
The nurse is caring for a Mexican American who is Catholic. The nurse wishes to
learn more about the culture by consulting a key informant. Which of the following
religious practitioners would be most knowledgeable about the
beliefs held by individuals of Mexican ethnicity?
A)
A church mother
B)
A voodoo priest
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C)
A curandera
D)
A peyote
leader Ans: C
Feedback:
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For Mexican Americans who are Roman Catholic, the priest and the curandera (a
secular folk healer) may be useful informants.
A)
Maintaining eye contact at all times.
B)
Trying to speak louder than usual.
C)
Using touch when communicating.
D)
Establishing effective communication.
Ans: D
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26.
A nurse is caring for an elderly woman from a far eastern culture. How does the nurse
demonstrate awareness of
culturally competent care?
Feedback:
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Establishment of an environment of culturally competent care and respect begins with
effective communication, which occurs not only through words, but also through
body language and other cues, such as voice, tone, and loudness.
Maintaining eye contact at all times is incorrect because not all cultures are
comfortable with eye contact; speaking louder is incorrect because the issue is a
communication problem, not a hearing problem; not all cultures are comfortable with
touch so this would block communication.
Americans
B)
British
C)
Canadians
D)
Native
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27.
Most nurses have been taught to maintain direct eye contact when communicating with clients.
Some cultural groups
would not value direct eye contact with the nurse. Which cultural group would consider the
direct eye contact impolite?
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Americans Ans: D
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Feedback:
Eye contact is also a culturally determined behavior. Although most nurses have been
taught to maintain eye contact when speaking with patients, some people from
certain cultural backgrounds may interpret this behavior differently. For example,
some Asians, Native Americans, Indo-Chinese, Arabs, and Appalachians may
consider direct eye contact impolite or aggressive, and they may avert their eyes
when talking with nurses and others whom they perceive to be in positions of
authority.
28.
The nurse is admitting a new client to the unit. The nurse notes that this client would need an
alternate meal choice when
the menu specified pork for a meal. What cultural group would require an alternative meal
choice?
A)
Christian
B)
Protestant
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C)
Muslim
D)
Mormon
Ans: C
Feedback:
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Many Muslim people abstain from eating pork.
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29.
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Personal space and distance is a cultural perspective that can impact nurse-client interactions.
What is the best way for
the nurse to interact physically with a client who has a different cultural perspective on space
and distance?
Know the client’s cultural personal space preferences.
B)
Realize that sitting close to the client is an indication of warmth and caring.
C)
Sit three to six feet away from the patient in an attempt to not offend.
D)
Remember not to intrude into the personal space of the elderly.
Ans: A
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Feedback:
When providing nursing care that involves physical contact, you should know the
client’s cultural personal space preferences. Sitting close to, or too far away from, the
patient may be interpreted as offensive. Age is not necessarily a deciding factor in
regards to a person’s cultural practices.
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A male nurse is preparing to take the vital signs of a female patient. Which ethnic group would
consider this improper?
A)
Native American
B)
Arab Muslim
C)
White
D)
African
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The Islamic religion does not allow the use of health care professionals of the
opposite gender unless it is impossible to locate one of the same gender. Native
Americans, Caucasians, and African Americans do not necessarily share this
sentiment.
A)
Chicken noodle soup with crackers, fruit crisp, and hot tea
B)
Turkey sandwich, small tossed salad, and iced tea
C)
Chef’s salad, bread, and water
D)
Fruit smoothie and granola
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31.
The nurse is admitting a client from China to the medical-surgical unit with a
diagnosis of cancer. While doing the client’s assessments, the client speaks of her
naturalistic beliefs related to health care and the importance of the yin/yang theory.
Based on her cancer diagnoses, the idea that cancer is considered a cold illness in the
culture, and her yin/yang
beliefs, which meal will the patient most likely order for lunch?
bar Ans: A
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In some Asian cultures, good health is thought to be achieved through the proper
balance of yin (feminine, negative, dark, cold) and yang (masculine, positive, light,
warm). Hot foods are eaten when a person has a cold illness, such as cancer, a
headache, and stomach cramps. Based on this information, the patient would likely
select chicken noodle soup with crackers, fruit crisp, and hot tea, as these are hot
foods. The other options are cold foods and would more likely be eaten when a
patient has a hot illness.
A)
Their health disparities
B)
Their societal beliefs
C)
The subgroup they belong to
D)
Their own cultural orientation.
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32.
The focal point of nursing is the nurse–client interaction. What must nurses consider when
conducting the necessary
assessment of their clients and significant others?
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Because the nurse–client interaction is the focal point of nursing, nurses should
consider their own cultural orientation when conducting assessments of patients and
their families and friends. Although nursing as a whole is actively recruiting more
diverse members, many nurses are members of, and have the same value systems
as, the dominant middle-class structure in the United States.
33.
When the South Asian client arrives 25 minutes late to her appointment at the clinic, the nurse
recognizes this as a sign
of which of the following?
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A)
Disrespect
B)
Laziness
C)
Respect
D)
Superiority
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Ans: C
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In some South Asian cultures, being late is considered a sign of respect. It may be
useful to note this in the client’s file and take it into account when scheduling future
appointments.
A)
Acculturation
B)
Cultural blindness
C)
Cultural imposition
D)
Stereotyping
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34.
What is the term that describes the inability of a person to recognize his or her own values,
beliefs, and practices as well
as those of others, because of strong ethnocentric tendencies?
Ans: B
Feedback:
Cultural blindness occurs when one ignores differences and proceeds as though they
do not exist, resulting in bias and stereotyping. Acculturation is the process by which
members of a culture adapt or learn how to take on the behaviors of another group.
Cultural imposition is the tendency to impose one’s cultural beliefs, values, and
patterns of behavior on a person from a different culture. Stereotyping is when one
assumes that all members of a culture, ethnic group, or race act alike.
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A)
Modern life facilitates healing agents.
B)
Healing takes time.
C)
Balancing yin and yang is important.
D)
Energy flows through meridians throughout the body.
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35.
The nurse caring for a Native American client plans care understanding that one belief of
Native American healing
practices is which of the following?
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Ans: B
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Native American healing practices are grounded in their cultural views. One
concept, identified in a study, is that healing takes time.
Chapter 6, Values, Ethics, and Advocacy
1.
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A nurse in a physician’s office has noted on several occasions that one of the
physicians frequently obtains controlled- drug prescription forms for prescription
writing. The physician reports that his wife has chronic back pain andrequires pain
medication. One day the nurse enters the physician’s office and sees him take a pill
out of a bottle. Thedoctor mentions that he suffers from migraines and that his wife’s
pain medication alleviates the pain. What type of nursephysician ethical situation is illustrated in this scenario?
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A)
Unprofessional, incompetent, unethical, or illegal physician practice
B)
Disagreements about the proposed medical regimen
C)
Conflicts regarding the scope of the nurse’s role
D)
Claims of loyalty
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Ans: A
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The physician is demonstrating unprofessional, incompetent, unethical, or illegal physician
practice.
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The client was diagnosed with diabetes three years ago, but has failed to integrate
regular blood glucose monitoring or dietary modifications into his lifestyle. He has
been admitted to the hospital for treatment of acute renal failure secondary to
diabetic nephropathy, an event that has prompted the client to reassess his values.
Which of the following
actions most clearly demonstrates that this client is engaging in the step of prizing within his
valuing process?
The client expresses pride that he now has the knowledge and skills to take control of his
diabetes management.
B)
The client states that he will now begin to check his blood glucose before each meal and at
bedtime.
C)
The client is now able to explain how his choices have contributed to his renal failure.
D)
The client expresses remorse at how his failure to take make lifestyle changes has adversely
affected his health.
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A)
Ans: A
Feedback:
Within the valuing process, expressions of pride and happiness are considered to be
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indications of prizing. Resolving to make changes is an aspect of choosing, while
expressing insight about his role in his current diagnosis demonstrates that the client
has the desire to re-examine his values.
A)
The decision should be made in light of consequences.
B)
The client’s autonomy and independence are the priority considerations.
C)
Benefits and burdens should be evenly distributed between the children and the client.
D)
The client has a right to self-determination.
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3.
The children of a female client 78 years of age with a recent diagnosis of early-stage
Alzheimer’s disease are attempting to convince their mother to move into an assisted
living facility, a move to which the client is vehemently opposed. Both the client and
her children have expressed to the nurse how they are entrenched in their position.
Which of the following
statements expresses a utilitarian approach to this dilemma?
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Ans: A
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Utilitarianism is the theory of ethics that weighs rightness and wrongness according
to consequences and outcomes for all those who are affected. Utilitarianism
prioritizes these consequences and outcomes over principles such as autonomy and
justice; principles that underlie the other statements addressing the patient’s right to
self-determination; and fair distribution of benefits and burdens.
4.
A group of nurse researchers has proposed a study to examine the efficacy of a new
wound care product. Which of the following aspects of the methodology
demonstrates that the nurses are attempting to maintain the ethical principle of
nonmaleficence?
A)
The nurses are taking every reasonable measure to ensure that no participants experience
impaired wound healing as a
result of the study intervention.
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C)
The nurses have given multiple opportunities for potential participants to ask questions, and
have been following the
informed consent process systematically.
D)
The nurses have completed a literature review that suggests the new treatment may result in
decreased wound healing
time.
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B)
The nurses have organized the study in such a way that the foreseeable risks and benefits are
distributed as fairly as
possible.
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Ans: A
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The principle of nonmaleficence dictates that nurses avoid causing harm. In this
study, this may appear in the form of taking measures to ensure that the intervention
will not cause more harm than good. The principle of justice addresses the distribution
of risks and benefits, and the informed consent process demonstrates that autonomy
is beingprotected. Preliminary indications of the therapeutic value of the intervention
show a respect for the principle of beneficence.
A)
Respecting the client’s desire to have the uncle make choices on her behalf
B)
Revisiting the decision when the uncle is not present at the bedside
C)
Teaching the client about her right to autonomy
D)
Holding a family meeting and encouraging the client to speak on her own behalf
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5.
A client with a diagnosis of colorectal cancer has been presented with her treatment
options, but wishes to defer any decisions to her uncle, who acts in the role of a
family patriarch within the client’s culture. By which of the following is
the client’s right to self-determination best protected?
Ans: A
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The right to self-determination (autonomy) means that it should never be forced on
anyone. The client has the autonomous right to defer her decision-making to another
individual if she freely chooses to do so.
A)
Paternalism
B)
Deception
C)
Harm
D)
Advocacy
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6.
A male client age 56 years is experiencing withdrawal from alcohol and is placing
himself at risk for falls by repeatedly attempting to scale his bedrails.
Benzodiazepines have failed to alleviate his agitation and the nurse is considering
obtaining an order for physical restraints to ensure his safety. The nurse should
recognize that this measure may
constitute what?
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Ans: A
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Paternalism involves the violation of a client’s autonomy in order to maximize good
or minimize harm, a situation that requires careful consideration in light of ethical
principles. Deception is unlikely to occur and the risk for harm is likely decreased by
the use of restraints. Advocacy is the protection and support of another’s rights.
7.
A mother always thanks clerks at the grocery store. Her daughter age 6 years echoes her thank
you. The child is
demonstrating what mode of value transmission?
A)
Modeling
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B)
Moralizing
C)
Reward and punishment
D)
Responsible choice
Ans: A
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Through modeling, children learn of high or low value by observing parents, peers,
and significant others. Modeling can thus lead to socially acceptable or unacceptable
behaviors. Children whose caregivers use the moralizing mode of value transmission
are taught a complete value system by parents or an institution (e.g., church or
school) that allows little opportunity for them to weigh different values. Through
rewarding and punishing, children are rewarded for demonstrating values held by
parents and punished for demonstrating unacceptable values. Caregivers who follow
the responsible-choice mode of value transmission encourage children to explore
competing values and to weigh their consequences.
Which of the following modes of value transmission is most likely to lead to confusion and
conflict?
A)
Modeling
B)
Moralizing
C)
Laissez-faire
D)
Responsible choice
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Ans: C
Feedback:
Those who use the laissez-faire approach for value transmission leave children to
explore values on their own (no one set of values is presented as best for all) and to
develop a personal value system. This approach often involves little orno guidance
and can lead to confusion and conflict.
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A)
modeling of value transmission
B)
conflict in values acceptance
C)
nonjudgmental “value neutral” care
D)
values conflict that may lead to stress
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9.
A nurse in a women’s health clinic values abstinence as the best method of birth control.
However, she offers
compassionate care to unmarried pregnant adolescents. What is the nurse demonstrating?
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Ans: C
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The nurse is demonstrating nonjudgmental “value neutral” care. This means she is
respecting and accepting the individuality of patients, does not assume that her
personal values are right, and does not judge the patients’ values as right or wrong
depending on their congruence with hers.
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10.
While at lunch, a nurse heard other nurses at a nearby table talking about a client they did not
like. When they asked him
what he thought, he politely refused to join in the conversation. What value was the nurse
demonstrating?
A)
The importance of food in meeting a basic human need
B)
Basic respect for human dignity
C)
Men do not gossip with women
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D)
A low value on collegiality and friendship
Ans: B
Feedback:
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Nurses who feel uncomfortable gossiping with other nurses about patients realize that
this behavior contradicts a basic respect for human dignity. This respect is a value
that allows one to choose freely to believe in the worth and uniqueness of each
individual.
A)
Ethical change strategy
B)
Values neutrality choices
C)
Values transmission
D)
Values clarification
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11.
A middle-aged man is having increasing difficulty breathing. He never exercises, eats
fast food regularly, and smokes two packs of cigarettes a day. He tells the nurse
practitioner that he wants to change the way he lives. What is one means
of helping him change behaviors?
Feedback:
Values clarification is a process by which people come to understand their own
values and value system. When nurses understand the values that motivate patients’
decisions and behaviors, they can tap these values when teaching and counseling
patients.
12.
A nurse using the principle-based approach to client care seeks to avoid causing harm to
clients in all situations. What is
this principle known as?
A)
Nonmaleficence
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B)
Justice
C)
Fidelity
D)
Autonomy
Ans: A
Feedback:
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The principle-based approach to ethics combines elements of both utilitarian and
deontologic theories and offers specific action guides for practice. The Beauchamp
and Childress principle-based approach to bioethics (2001) identifies four key
principles: autonomy (promote self-determination), nonmaleficence (avoid causing
harm), beneficence (benefit the patient), and justice (act fairly).
A)
Code of Ethics
B)
Standards of Care
C)
Definition of Nursing
D)
Values
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13.
A nurse provides client care within a philosophy of ethical decision making and professional
expectations. What is the
nurse using as a framework for practice?
Clarification Ans:
A
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Feedback:
A professional code of ethics provides a framework for making ethical decisions and
sets forth professional expectations. Codes of ethics inform both nurses and society
of the primary goals and values of the profession.
A)
Nurse must follow the physician’s orders
B)
An inability to provide care for the patient
C)
An ethical dilemma about inconsistent courses of action
D)
A barrier to establishing an effective nurse–patient relationship
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14.
A client nearing the end of life requests that he be given no food or fluids. The physician
orders the insertion of a
nasogastric tube to feed the client. What situation does this create for the nurse providing care?
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Ans: C
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In an ethical dilemma, two or more clear moral principles apply but support mutually
inconsistent courses of action. In this case, the nurse must decide what to do based
on ethical decision making and take action that can be justified ethically based on
that process.
15.
Two children need a kidney transplant. One is the child of a famous sports figure, whereas the
other child comes from a
low-income family. What ethically relevant consideration is important to the nurse as an
advocate for these clients?
A)
Balance between benefits and harms in patient care
B)
Norms of family life
C)
Considerations of power
D)
Cost-effectiveness and allocation
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Ans: D
Feedback:
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The increasing awareness of how difficult it is to make valued and scarce health
resources available to all in need has resulted in a new appreciation for the moral
relevance of cost-effectiveness. Balance between benefits and harms in patient care
relates to reasoning about the benefits or burdens of treatment and the related harms;
in this scenario, both children’s risk and benefits may be the same. Norms of family
life relate to the ways a client’s illness impacts family members and significant
others; not enough information is provided to know how this ethical principle applies
in this scenario. Considerations of power relates to abuse of power by clinicians; this
scenario does not present information suggesting this is occurring.
A)
Confidentiality
B)
Accountability
C)
Trust
D)
Informed consent
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16.
A student nurse is working in the library on her plan of care for a clinical assignment. The
client’s name is written at the
top of her plan. What ethical responsibility is the student violating?
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The student is violating confidentiality. Confidentiality is violated when patients are
identified by name on written documents available to those who are not directly
responsible for their care.
A)
The client’s family
B)
The admitting physician
C)
The nurse in charge of the unit
D)
The institutional ethics committee
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17.
A nurse is concerned about the practice of routinely ordering a battery of laboratory
tests for clients who are admitted to the hospital from a long-term care facility. An
appropriate source in handling this ethical dilemma would be which of the
following?
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Many health care institutions have developed ethics committees whose functions
include education, policymaking, case review, and consultation. These committees
are multidisciplinary and provide a forum where divergent views can be discussed
without fear of repercussion.
18.
A client, unsure of the need for surgery, asks the nurse, “What should I do?” What answer by
the nurse is based on
advocacy?
A)
“If I were you, I sure would not have this surgical procedure.”
B)
“Gosh, I don’t know what I would do if I were you.”
C)
“Tell me more about what makes you think you don’t want surgery.”
D)
“Let me talk to your doctor and I will get back to you as soon as I can.”
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Ans: C
Feedback:
Nurses as advocates must realize that they do not make ethical decisions for their
clients. Rather, they facilitate clients’ decision-making by interpreting findings,
informing cliients of various aspects to be considered, helping clients verbalize and
organize their feelings, calling in others involved in the decision making, and
helping clients assess all their options in relation to their beliefs.
A)
Imaginal skills
B)
Interpersonal skills
C)
Instrumental skills
D)
Systems skill
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19.
A client who is scheduled to have surgery for a hernia the next day is anxious about
the whole procedure. The nurse assures the client that surgery for hernias is very
common and that the prognosis is very good. What skills of the nurse
are reflected here?
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Ans: B
Feedback:
The scenario reflects the nurse’s interpersonal skills. It shows how a person relates
with others. The nurse shows imaginal skills when he or she envisions a plan for
adapting and personalizing client care. Instrumental skills are associated with basic
physical and intellectual competencies. Systems skills are those that help the nurse
see the whole picture and how various parts relate.
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A)
Veracity
B)
Fidelity
C)
Confidentiality
D)
Autonomy
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20.
A nurse is caring for a client who is a celebrity in the area. A person claiming he is a
family member inquires about the medical details of the client. The nurse reveals the
information but later comes to find out that the person was not a
family member. The nurse has violated which of the following?
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Ans: C
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The nurse has violated the principle of confidentiality by revealing the client’s
personal medical information to a third person. Confidentiality is a professional duty
and a legal obligation. What is documented in the client’s record is accessible only to
those providing care to that client. The nurse’s action does not violate rules of
veracity, fidelity, or autonomy. Fidelity means being faithful to one’s commitments
and promises. Veracity means telling the truth, which is essential to the integrity of
the client-provider relationship. Autonomy involves a client making his or her own
decisions.
A nursing instructor is teaching a class about ethical principles to a group of nursing students.
The instructor determines
that the teaching was successful when the students give which of the following as an example
of nonmaleficence?
A)
Protecting clients from a chemically impaired practitioner
B)
Performing dressing changes to promote wound healing
C)
Providing emotional support to clients who are anxious
D)
Administering pain medications to a client in pain
Ans: A
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Feedback:
Protecting clients from a chemically impaired practitioner is an appropriate example
of nonmaleficence. Nonmaleficence means to avoid doing harm, to remove from
harm, and to prevent harm. Performing dressing changes to promote wound healing,
providing emotional support to clients who are anxious, and administering pain
medications to a client in pain are examples of beneficence, which means doing or
promoting good.
A)
Arrange a meeting between the family and the client.
B)
Help the patient clarify his values.
C)
Educate the patient on death and dying concepts.
D)
Allow the patient time for quiet reflection.
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22.
A dying client tells the nurse that he doesn’t want to see his family because he doesn’t want to
cause them more sadness.
Which action by the nurse is most appropriate?
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Ans: B
Values clarification is a method of self-discovery by which people identify their
personal values and value rankings. The client’s value of family may be obscured
because of his overwhelming need to protect his family.
23.
A nurse is caring for a client who is a practicing Jehovah’s Witness. The physician
orders two units of packed cells based on his low hemoglobin and hematocrit levels.
The nurse states to the surgeon that it is unethical to go against the
patient’s beliefs even though his blood counts are very low. What is the best description of the
nurse’s intentions?
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A)
Acting in the patient’s best interest
B)
Siding with the patient over the surgeon
C)
Observing institutional policies
D)
Being legally responsible
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Ans: A
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Nurses’ ethical obligations include acting in the best interest of their clients, not only
as individual practitioners, but also as members of the nursing profession, the health
care team, and the community at large.
What is the function of the American Nurses Association’s Code of Ethics for Nurses?
A)
Serves to establish personal ethics for nurses
B)
Delineates nurses’ conduct and responsibilities
C)
Serves as a guideline for all health care practice
D)
Plays an important role in legal proceedings
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Ans: B
Feedback:
The ANA recently revised the Code of Ethics for Nurses that delineates the conduct
and responsibilities expected of all nurses in their nursing practices.
25.
When a nurse refuses to compromise a client’s right to privacy, even when the nurse is
threatened, the nurse is
expressing an ethical framework termed what?
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A)
Utilitarian
B)
Deontologic
C)
Justice
D)
Nonmaleficence
Ans: B
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Deontologic frameworks emphasize roles or responsibilities that one is morally obligated to
fulfill.
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26.
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A nurse is caring for a woman 28 years of age who has delivered a baby by Cesarean section.
She describes her pain as a
9. The nurse medicates her for pain. This is an example of which of the following ethical
frameworks?
Justice
B)
Fidelity
C)
Beneficence
D)
Nonmaleficence
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A)
Ans: C
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Beneficence means doing or promoting good. The treatment of the client’s pain is the nurse’s
act of doing good.
A)
Justice
B)
Autonomy
C)
Nonmaleficence
D)
Fidelity
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27.
A home care nurse visits a client who is confined to bed and is cared for by her
daughter. The daughter is known to suffer from chemical dependence. The home is
cluttered and unclean. During the assessment the nurse notes that the client is wet
with urine and has dried feces on her buttocks, and demonstrates signs of
dehydration. After caring for the client, the nurse contacts the physician and reports
the incident to Adult Protective Services. This is an example of which
ethical framework?
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Ans: C
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The principle of nonmaleficence means to avoid doing harm, to remove harm, and to
prevent harm. Autonomy means to respect the rights of clients or their surrogates to
make healthcare decisions. Justice means to give each his or her due. Fidelity means
to keep promises.
28.
A woman age 83 years who has suffered a cerebrovascular accident and is unable to swallow
refuses the insertion of a
feeding tube. This is an example of what ethical principle?
A)
Nonmaleficence
B)
Veracity
C)
Autonomy
D)
Justice
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Ans: C
Feedback:
Autonomy essentially means independence and the ability to be self-directed.
A)
Fidelity
B)
Veracity
C)
Justice
D)
Autonomy
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29.
A nurse states to the client that she will keep her free of pain. However, her family
wishes to try a treatment to prolong her life that may necessitate withholding pain
medication. This factor will cause an ethical dilemma for the nurse in
relation to which ethical principle?
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Ans: A
Fidelity means being faithful to one’s commitments and promises.
30.
Which of the following are examples of a nurse demonstrating the professional value of
altruism? Select all that apply.
A)
The nurse arranges for an interpreter for a client whose primary language is Spanish.
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B)
The nurse calls the physician of a client whose pain medication is not strong enough.
C)
The nurse provides information for a client so he is capable of participating in planning his
care.
D)
The nurse reviews a client chart to determine who may be informed of the patient’s condition.
E)
The nurse documents client care accurately and honestly and reviews the entry to ensure there
are no errors.
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The altruistic nurse demonstrates understanding of cultures, beliefs, and perspectives
of others; advocates for clients; and takes risks on behalf of clients and colleagues.
The professional practice reflects autonomy when the nurse respects clients’ rights to
make decisions about their health care. Human dignity is reflected when the nurse
values and respects all clients and colleagues by preserving their confidentiality.
Integrity is reflected in professional practice when the nurse is honest and provides
care based on an ethical framework that is accepted within the profession. Social
justice is upholding moral, legal, and humanistic principles. One way to do this is by
encouraging legislation and policy consistent with the advancement of nursing care
and health care.
A nurse has a duty of nonmaleficence. Which of the following would be considered a
contradiction to that duty?
A)
Provide comfort measures for a terminally ill patient.
B)
Assist the patient with ADLs.
C)
Refuse to administer pain medication as ordered.
D)
Provide all information related to procedures.
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Ans: C
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B)
The nurse calls the physician of a client whose pain medication is not strong enough.
The duty not to inflict harm, as well as prevent and remove harm, is termed
nonmaleficence. Providing comfort measures for a terminally ill patient, assisting a
patient with ADLs and providing information related to procedures would not be
considered a contradiction to the nurse’s duty of nonmaleficence.
A)
It limits personal safety.
B)
It increases confusion.
C)
It threatens autonomy.
D)
It prevents self-directed care.
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32.
A nurse working in a long-term care facility has an elderly male client who is very confused.
What ethical dilemma is
posed when using restraints in a long-term care setting?
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Because there are safety risks involved when using restraints on elderly confused
clients, this is a common ethical problem in long-term care settings, as well as other
health care settings. Restraints limit the individual’s autonomy because they are
perceived as imprisonment. Restraints should not limit personal safety. Often,
restraints increase confusion, and they prevent self-directed care.
33.
A home health nurse who performs a careful safety assessment of the home of a frail elderly
patient to prevent harm to
the patient is acting in accord with which of the following, a principle of bioethics?
A)
Nonmaleficence
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B)
Advocacy
C)
Morals
D)
Values
Ans: A
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Nonmaleficence is a principle of bioethics and is defined as the obligation to prevent
harm. Advocacy, morals, and values are not principles of bioethics.
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34.
A nurse has had, on several occasions, the opportunity to share personal prescriptions with
family members when they
were in need of pain medication or antibiotics. Which set of rules should govern this moral
decision?
Ethics
B)
Administrative law
C)
Common law
D)
Civil law
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Although all of the options may affect your decision, moral decisions are guided by
ethics, which are internal set of principles and values that guide the behavior of a
person. Sharing medications prescribed to you with other people, including family
members, would be considered unethical. It is important to distinguish ethics from
law, religion, custom, and institutional practices. For example, the fact that an action
is legal or customary does not in itself make the action ethically or morally right.
An ethical conflict exists around a female client’s expressed desire to have a
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neighbor make her treatment decisions. This neighbor is an individual who the
client’s children characterize as a predator. Place in the correct order the steps that
the nurse should follow in resolving this ethical conflict.
1.
Clearly identify the ethical problem
2.
Apply ethical principles to the situation
3.
Identify the different options
4.
Gather relevant data about the situation
5. Make and evaluate a decision
A)
1, 2, 3, 4, 5
B)
4, 1, 3, 2, 5
C)
2, 3, 4, 1, 5
D)
1, 4, 3, 2, 5
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The nursing process of assessment, diagnosis, planning, implementation, and
evaluation can be applied to appropriately respond to many ethical dilemmas.
Chapter 7, Legal Dimensions of Nursing Practice
Which of the following aspects of nursing would be most likely defined by legislation at a
state level?
A)
The differences in the scope of practice between registered nurses (RNs) and licensed practical
nurses (LPNs).
B)
The criteria that a nurse must consider when delegating tasks to unlicensed care providers.
C)
The criteria that clients must meet in order to qualify for Medicare or Medicaid.
D)
The process that nurses must follow when handling and administering medications.
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The scope of practice defines the parameters within which nurses provide care, and is
established by state legislation, most commonly in the form of a Nurse Practice Act.
The criteria and due process for delegation in the clinical setting is addressed by a
state board of nursing. Qualification criteria for programs such as Medicare and
Medicaid are established by federal legislation, while the process for safe and
appropriate medication administration is defined and monitored by a state board of
nursing.
2.
During a clinical placement on a subacute, geriatric medicine unit, a student nurse fed
a stroke client some beef broth, despite the fact that the client’s diet was restricted to
thickened fluids. As a result, the client aspirated and developed
pneumonia. Which of the following statements underlies the student’s potential liability in this
situation?
A)
The same standards of care that apply to a registered nurse apply to the student.
B)
The student and the nursing instructor share liability for this lapse in care.
C)
The patient’s primary nurse is liable for failing to ensure that delegated care was appropriate.
D)
The student’s potential liability is likely negated by the insurance carried by the school of
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nursing.
Ans: A
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Despite the fact that their knowledge and skills are still under development, nursing
students are held to the same standards of care as registered nurses. Consequently,
primary liability does not lie with the student’s instructor or the patient’s primary
nurse. Insurance may be carried by the school of nursing, but this does not negate the
student’s legal responsibility to provide care at a high standard.
A nurse is arrested for possession of illegal drugs. What kind of law is involved with this type
of activity?
A)
Civil
B)
Private
C)
Public
D)
Criminal
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Criminal law concerns state and federal criminal statutes, which define criminal
actions such as murder, manslaughter, criminal negligence, theft, and illegal
possession of drugs. Civil law, also called private law, includes laws relating to
contracts, ownership of property, and the practice of nursing, medicine, pharmacy,
and dentistry. Public law is law in which the government is involved directly.
A)
Public law
B)
Statutory law
C)
Common law
D)
Administrative law
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4.
A lawyer quotes a precedent for punishment of a crime committed by the defendant in a trial.
What is court-made law
known as?
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The government provides for a judiciary system, which is responsible for reconciling
controversies. It interprets legislation at the local, state, and national levels as it has
been applied in specific instances and makes decisions concerning law enforcement.
A body of law known as common law has evolved from these accumulated judiciary
decisions. Common law is thus court-made law, and most law involving malpractice
is common law.
5.
A client is suing a nurse for malpractice. What is the term for the person bringing suit?
A)
Plaintiff
B)
Defendant
C)
Litigator
D)
Witness
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Ans: A
Feedback:
A lawsuit is a legal action in a court. Litigation is the process of bringing and trying a
lawsuit. The person or government bringing suit against another is called the plaintiff.
The one being accused of a crime or tort (defined later) is called the defendant. The
defendant is presumed innocent until proved guilty of a crime or tort.
A)
The nurse
B)
The head nurse
C)
The physician
D)
The hospital
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6.
A nurse is providing client care in a hospital setting. Who has full legal responsibility and
accountability for the nurse’s
actions?
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In modern practice, nurses assess and diagnose clients and plan, implement, and
evaluate nursing care. Full legal responsibility and accountability for these nursing
actions rest with the nurse.
7.
What type of law regulates the practice of nursing?
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A)
Common law
B)
Public law
C)
Civil law
D)
Criminal law
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Civil laws regulate the practice of nursing. A law is a standard or rule of conduct
established and enforced by the government, chiefly to protect the rights of the
public. Private law, also called civil law, regulates relationships among people and
includes laws related to the practice of nursing.
What is the legal source of rules of conduct for nurses?
A)
Agency policies and protocols
B)
Constitution of the United States
C)
American Nurses Association
D)
Nurse Practice Acts
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Ans: D
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Nurse Practice Acts are examples of statutory law, enacted by a legislative body in
keeping with both the federal constitution and the applicable state constitution. They
are the primary source of rules of conduct for nurses. Standards of practice, which
differ from rules of conduct, are made by agency policies and protocols and by the
American Nurses Association.
9.
A nurse moves from Ohio to Missouri. Where can a copy of the Nurse Practice Act in
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Missouri be obtained?
A)
Ohio State Board of Nursing
B)
Missouri State Board of Nursing
C)
Federal government nursing guidelines
D)
National League for Nursing
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Each state has a Nurse Practice Act that protects the public by broadly defining the
legal scope of nursing practice. A copy of the Nurse Practice Act for the state in
which a nurse practices can be obtained from that state’s board of nursing. Neither the
federal government nor the National League for Nursing has copies of nurse practice
acts.
Which of the following best describes voluntary standards?
A)
Voluntary standards are guidelines for peer review, guided by the public’s expectation of
nursing.
B)
Voluntary standards set requirements for licensure and nursing education.
C)
Voluntary standards meet criteria for recognition, specified area of practice.
D)
Voluntary standards determine violations for discipline and who may practice.
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Ans: A
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Voluntary standards are developed and implemented by the nursing profession itself.
They are not mandatory but are used as guidelines for peer review. The organizations
that set standards are guided by society’s need for nursing and by the public’s
expectations of nursing.
Which of the following accreditations is a legal requirement for a school of nursing to exist?
A)
National League for Nursing Accrediting Commission
B)
American Association of Colleges of Nursing accreditation
C)
State Board of Nursing accreditation
D)
Educational institution accreditation
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11.
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State laws are enacted to ensure that schools preparing nursing practitioners maintain
minimum standards of education. This is legal accreditation. Accreditation by
voluntary agencies is not required for a school to exist.
12.
Which of the following is the most frequent reason for revocation or suspension of a nurse’s
license?
A)
Fraud
B)
Mental impairment
C)
Alcohol or drug abuse
D)
Criminal acts
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Ans: C
Feedback:
A nurse’s license may be suspended or revoked for fraud, deceptive practices, criminal
acts, previous disciplinary action by other state boards, negligence, physical or mental
impairments, or alcohol or drug abuse. The most frequent reason is alcohol or drug
abuse.
A)
Assault
B)
Battery
C)
Fraud
D)
Negligence
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13.
A nurse does not assist with ambulation for a postoperative client on the first day after
surgery. The client falls and
fractures a hip. What charge might be brought against the nurse?
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A tort is a civil wrong committed by a person against another person or his or her
property. Negligence, an unintentional tort, occurs when a person fails to exercise
reasonable care in the performance of his or her duties. In this situation, the nurse did
not initiate proper precautions to prevent patient harm and is subject to the charge of
negligence.
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Assault
B)
Battery
C)
Negligence
D)
Defamation
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14.
A client refuses to have a pain medication administered by injection. A nurse says, “If you
don’t let me give you the
shot, I will get help to hold you down and give it.” With what crime might the nurse be
charged?
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Assault and battery are intentional torts. Assault is a threat or attempt to make bodily
contact with another person without that person’s consent. Threatening to forcibly
administer an injection after the patient has refused it is assault. Battery is an assault
that is carried out and includes willful, angry, and violent or negligent touching of
another person’s body, clothes, or anything attached to or held by that other person.
Negligence is defined as performing an act that a reasonably prudent person under
similar circumstances would not do or, conversely, failing to perform an act that a
reasonably prudent person under similar circumstances would do. Defamation is an
intentional tort in which one party makes derogatory remarks about another that
diminish the other party’s reputation.
15.
Two nurses are discussing a client’s condition in an elevator full of visitors. With what crime
might the nurses be
charged?
A)
Defamation of character
B)
Invasion of privacy
C)
Unintentional negligence
D)
Intentional negligence
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Ans: B
Feedback:
Certain acts by nurses could constitute invasion of privacy, including talking about
patients in public areas, such as elevators. This violates federal law. In this case, the
nurses would not be charged with defamation or negligence.
A)
Damages
B)
Causation
C)
Duty
D)
Breach of duty
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16.
A lawsuit has been brought against a nurse for malpractice. The client fell and
suffered a skull fracture, resulting in a longer hospital stay and need for rehabilitation.
What does the description of the client and his injuries represent as proof
of malpractice?
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Ans: A
Liability involves four elements: duty (obligation to use care and follow standards),
breach of duty (failure to follow standards of care), causation (the failure to follow
standards of care resulted in the injury), and damages (the actual harm or injury
resulting to the patient).
17.
A nurse has been named as a defendant in a lawsuit. With whom should the nurse discuss the
case?
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A)
Colleagues
B)
Reporters
C)
Plaintiff
D)
Attorney
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The nurse should only discuss the case with the attorney representing him or her
and/or the institution. Recommendations for the nurse as defendant include not
discussing the case with anyone at the employing agency (except the risk manager),
the plaintiff, the plaintiff’s lawyer, anyone testifying for the plaintiff, or reporters.
Which of the following is the nurse’s best legal safeguard?
A)
Collective bargaining
B)
Written or implied contracts
C)
Competent practice
D)
Patient education
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Ans: C
Feedback:
Competent practice is the nurse’s most important and best legal safeguard. Each
nurse is responsible for making sure his or her educational background and clinical
experience are adequate to fulfill the nursing responsibilities described in the job
description. Collective bargaining, written or implied contracts, and/or patient
education do not provide the best legal safeguard.
A nurse has taken a telephone order from a physician for an emergency medication. The dose
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A)
Administer the medication based on the order
B)
Question the order for the medication
C)
Refuse to administer the medication
D)
Document concerns about the order
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of the medication is
abnormally high. What should the nurse do next?
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The nurse should question any physician order that is ambiguous, contraindicated by
normal practice (such as an abnormally high medication dose), or contraindicated by
the client’s present condition. The nurse should not administer the medication, refuse
to administer the medication without contacting the physician, or document concerns
about the order without doing anything further.
A)
The physician in charge should fill out the report.
B)
The names of the staff involved should not be included.
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20.
A client gets out of bed following hip surgery, falls, and re-injures her hip. The nurse
caring for her knows that it is her duty to make sure an incident report is filed. Which
of the following statements accurately describes the correct
procedure for filing an incident report?
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C)
The reports are used for disciplinary action against the staff.
D)
The report should contain all the variables related to the incident.
Ans: D
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An incident report, also called a variance or occurrence report, is used by health care
agencies to document the occurrence of anything out of the ordinary that results in, or
has the potential to result in, harm to a patient, employee, or visitor. The nurse
responsible for a potentially (or actually) harmful incident or who witnesses an injury
is the one who fills out the incident form. This form should contain the complete
name of the person or people involved and the names of all witnesses; a complete
factual account of the incident; the date, time, and place of the incident; pertinent
characteristics of the person or people involved (e.g., alert, ambulatory, asleep) and
of any equipment or resources being used; and any other variables believed to be
important to the incident. These reports are used for quality improvement and should
not be used for disciplinary action against staff members.
A)
Keep silent and overlook the incident
B)
Inform the local police station
C)
Discuss this incident with the colleague
D)
Report the incident to the supervisor
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21.
An on-duty nurse discovers that her colleague is pilfering medicines. According to the Nurse
Practice Acts, what should
the nurse do?
Ans: D
Feedback:
According to the Nurse Practice Acts, the nurse should report the incident to the
supervisor. Laws are enacted to regulate the practice of nursing and may be used to
decide upon an appropriate action. Discussing the incident with a colleague may
alarm the nurse who is pilfering medicines and she may become cautious. The nurse
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should not overlook the incident because pilfering of medicines is an offense. Calling
local police may lead to undue interference.
A)
The nurse did not call the physician when the client asked.
B)
The nurse did not realize the importance of the tube.
C)
The dietary department sent the wrong diet for the client.
D)
The nurse insisted the patient have the solid food.
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22.
A client who has undergone resection of the intestine is on a liquid diet with a
nasogastric tube in place. He refuses the food tray with regular food that comes to his
room and insists that a physician be called. The nurse insists that it is the right food
and makes the client take it. The client develops complications and has to be reoperated upon. How is
negligence determined in this situation?
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Negligence is defined as harm that occurs because the person did not act reasonably.
In this case, the nurse did not realize that the client was on a nasogastric tube, and
should consequently have been on liquid feeds after intestinal surgery; as a result, the
patient developed complications. The acts of not calling the physician and insisting
the patient have food do not amount to negligence. The dietary department sending
the wrong food is unrelated to the nurse.
23.
A home care nurse is caring for a quadriplegic client who needs regular position
changes and back massages. A gentleman identifying himself as a family friend
inquires if he can be of any help to the family. What should be the
nurse’s response be?
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A)
The nurse should ask the gentleman to talk to the family directly.
B)
The nurse should invite the gentleman to learn the caring techniques.
C)
The nurse should state that the family does not need any help.
D)
The nurse should refer the gentleman to the local social worker.
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The nurse should ask the gentleman to talk to the family directly. Revealing
information about the client’s care is a violation of the client’s privacy. The nurse
should not invite the gentleman for a learning session because it would be a breach of
the client’s right to privacy. Referring him to a social worker is not an appropriate
choice.
A)
The client was trying to lower the side rails.
B)
The client was found lying on the floor.
C)
The client was trying to get out of the bed.
D)
The client was not aware that he had fallen.
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24.
A client is admitted with symptoms of psychosis. The nurse hurries to the client’s
room when she hears the client calling for help. She finds the client lying on the
ground. The nurse assists the client back to the bed and performs a thorough
assessment. The nurse informs the physician and completes the incident report.
Which of the following statements
should the nurse document in the incident report?
Ans: B
Feedback:
An incident report is a written account of an unusual, potentially injurious event
involving a client, employee, or visitor. All of the details given in the incident report
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should be accurate and not assumed. Accurate and detailed documentation helps to
prove that the nurse acted reasonably or appropriately in the circumstance. The nurse
should document that the client was found lying on the floor. The other statements are
assumptions and should not be included in the incident report.
A)
Criminal
B)
Federal
C)
Civil
D)
Supreme
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25.
A nurse fails to administer a medication that prevents seizures, and the client has a seizure.
The nurse is in violation of
the Nurse Practice Act. What type of law is the nurse in violation of?
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Malpractice cases are generally the kind of civil cases that involve nurses.
A baccalaureate-prepared nurse is applying for a nurse practitioner position. The nurse is:
A)
Well educated and can perform these duties
B)
Able to practice as a nurse practitioner
C)
Educated to practice only with pediatric patients
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D)
Practicing beyond his scope according to licensure
Ans: D
Feedback:
A nurse without an advanced practice license is not able to practice beyond his or
her scope in accordance with the Nurse Practice Act.
A)
Battery
B)
Assault
C)
Invasion of privacy
D)
Dereliction of duty
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27.
When the nurse inserts an ordered urinary catheter into the client’s urethra after the client has
refused the procedure, and
then the client suffers an injury, the client may sue the nurse for which type of tort?
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Ans: A
Battery is the actual carrying out of such threat (unlawful touching of a person’s
body). A nurse may be sued for battery if he or she fails to obtain consent for a
procedure.
28.
A group of nurses working in a long-term care facility fails to keep the narcotic
medications in a secure location. The nurses also fail to count the medications before
and after each shift, as indicated by the institution’s policies and
procedures. These failures may result in what type of disciplinary action?
A)
Action against the nurses’ licenses
B)
Action against the facility’s state license
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C)
Action against the state regulating body
D)
Action against the pharmacist’s license
Ans: A
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In institutions, most controlled substances must be kept secure and monitored closely
in accordance with institutional and state regulations. Failure to do so may lead to
disciplinary action against the nurse’s license.
A)
Credentialing refers to the way in which professional competence is ensured and maintained.
B)
Accreditation is the process by which the state determines that a person meets minimum
requirements to practice
nursing.
C)
Certification grants recognition in a specified practice area to people who meet certain criteria.
D)
Legal accreditation of a school preparing nursing personnel by the state Board of Nursing is
voluntary.
E)
Once earned, a license to practice is a property right and may not be revoked without due
process.
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29.
Which of the following statements accurately describes an aspect of the credentialing process
used in nursing practice?
Select all that apply.
Ans: A, C, E
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Credentialing refers to the way in which professional competence is ensured and
maintained. Licensure is the process by which a state determines that a candidate
meets certain minimum requirements to practice in the profession and grants a
license to do so. Certification is the process by which a person who has met certain
criteria established by a nongovernmental association is granted recognition in a
specified practice area. State accreditation is a legal requirement; legal accreditation
of a school preparing nursing personnel by the state Board of Nursing should not be
confused with voluntary accreditation. Once earned, a license to practice is a
property right and may not be revoked without due process. This includes notice of
an investigation, a fair and impartial hearing, and a proper decision based on
substantial evidence. According to the National Council of State Boards of Nursing,
a mutual recognition model of nurse licensure exists that allows a nurse to have one
license in his or her state of residency, and to practice in other states (both physically
and electronically) as well, subject to each state’s practice law and regulation, unless
otherwise restricted.
A)
To see the health record
B)
To copy the health record
C)
To make additions to the health record
D)
To cross out sections of the health record
E)
To restrict certain disclosures of the health record
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30.
According to HIPPA regulations, which of the following is a client right regarding the client’s
medical record? Select all
that apply.
Ans: A, B, E
Feedback:
According to HIPAA, clients have a right to see and copy their health record; to
update their health record; to get a list of the disclosures a health care institution has
made independent of disclosures made for the purposes of treatment, payment, and
health care operations; to request a restriction on certain uses or disclosures; and to
choose how to receive health information. The client may not make additions, cross
out sections, or destroy the health record.
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A)
Disclosure
B)
Organ donation
C)
DNR orders
D)
Comprehension
E)
Competence
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31.
A nurse explains the informed consent form to a client who is scheduled for heart bypass
surgery. Which of the
following are elements of this consent form? Select all that apply.
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Every person is granted freedom from bodily contact by another person, unless
consent is granted. In all health care agencies, informed and voluntary consent is
needed for admission (for routine treatment), for each specialized diagnostic
procedure or medical or surgical treatment, and for any experimental treatments or
procedures. Elements of informed consent include disclosure, comprehension,
competence, and voluntariness.
32.
Which of the following nursing actions would be considered a violation of HIPPA
regulations? Select all that apply.
A)
A nurse ambulates a client through a hospital hallway in a hospital gown that is open in the
back.
B)
A nurse shoves a confused, bedridden client into bed after he made several attempts to get up.
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C)
A nurse inadvertently administers the wrong dose of morphine to a client in the ICU.
D)
A nurse uses a client’s chart as a sample teaching case without changing the client’s name.
E)
A nurse reports the condition of a client to the client’s employer.
Ans: A, D, E
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HIPPA regulations exist to protect patient privacy. Answers A, D, and E are
examples of violations of HIPPA. Shoving a patient is battery and inadvertently
administering the wrong dose of a medicine is negligence. A person fraudulently
misrepresenting himself or herself to obtain a license to practice nursing is
considered fraud.
A)
The client scheduled for a cholecystectomy has a total abdominal hysterectomy.
B)
The client receives preoperative medication before signing the informed consent.
C)
The client receives a medication and develops a rash on the trunk of the body, itching, and
dyspnea.
D)
The client fails to receive a regularly scheduled medication.
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33.
The nursing student asks the nurse for an example of a “never event.” Which example
provided by the nurse best
answers the nursing student’s question?
Ans: A
Feedback:
A “never event” is an extremely rare medical error that should never occur. The
performance of the wrong surgery on a client is an example of a never event. The
other examples are examples of incidents or variances, events that occur out of the
ordinary that result in, or have the potential to result in, harm to a client, employee,
or visitor.
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1.
The nurse reports a nursing colleague on the unit who is lethargic and verbally responding in a
slow manner. What is
an example of?
A) Whistle-blowing
B)
Collective bargaining
C)
Delegating nursing care
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D) Ensuring adequate staffing
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Whistle-blowing is when the nurse reports unsafe practice environments. Impaired
nurses threaten the safety of clients in the clinical setting, as does inadequate staffing.
Nurses may delegate or assign tasks involved in the delivery of nursing care to
individuals as long as the individual has sufficient knowledge and skill to perform the
assigned task. Collective bargaining is a legal process in which representatives of
organized employees negotiate with employers about work conditions.
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The nurse is accused of malpractice by a client. List the order in which the steps of
the litigation process will occur (use all options).
1) The basis for the claim is determined to be appropriate and timely with all elements of
liability present.
2.
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2) All parties named as defendants (nurses, physicians, health care agency), as well
as insurance companiesand attorneys, work toward a fair settlement.
3) Trial takes place; both sides present their evidence and arguments.
4) The case is presented to a malpractice arbitration panel. The panel’s decision is
either accepted or rejected, inwhich case a complaint is filed in trial court.
5) Pretrial discovery activities occur: review of medical records and depositions of plaintiff,
defendants, andwitnesses.
C)
1, 2, 3, 4, 5, 6
D)
2, 6, 5, 3, 1, 4
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6) The defendants contest allegations.
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The steps involved in malpractice litigation are as follows: 1. The basis for the claim
is determined to be appropriate and timely; all elements of liability are present (duty,
breach of duty, causation, and serious damages). 2. All parties named as defendants
(nurses, physicians, health care agency), as well as insurance companies and
attorneys, work toward a fair settlement. 3. The case is presented to a malpractice
arbitration panel. The panel’s decision is either accepted or rejected, in which case a
complaint is filed in trial court. 4. The defendants contest allegations (argue that there
is no basis for alleging deviation from the appropriate standard of care or for proving
causation and damages). 5. Pretrial discovery activities occur: review of medical
records and depositions of plaintiff, defendants, and witnesses. 6. Trial takes place;
both sides present their evidence and arguments. 7. Decision or verdict is reached by
the judge and/or jury. 8. If the verdict is not accepted by both sides, it may be
appealed to an appellate court.
Chapter 8, Communication
A group of nursing students is working together on a presentation for their clinical
instructor. One student in the group participates by arguing and attempting to block
each step of the process of this presentation. The student’s behavior is causing
frustration for the others and slowing their progress. Which of the following best
describes the role this
1.
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A)
Self-serving
B)
Task-oriented
C)
Maintenance
D)
Group-building
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Ans: A
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The student’s behavior is best described as self-serving. Self-serving roles advance
the needs of individual members at the group’s expense. Task-oriented roles focus on
the work to be completed. Group-building or maintenance roles focus on the wellbeing of the people doing the work.
A)
Using a caring voice and repeating messages frequently
B)
Speaking directly and loudly to the client
C)
Avoiding the use of gesture or
play-acting
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2.
The nurse is caring for a client who speaks Chinese, and the nurse does not speak Chinese. An
appropriate approach for
communication with this client includes what?
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D)
Writing messages for the client and offering him a dictionary for translation.
Ans: A
Feedback:
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Approaches to use when a client speaks a different language include speaking slowly
and distinctly, and avoiding loud voices. Use a caring voice, keeping messages simple,
and repeat messages frequently. The use of a language dictionary by the nurse is
appropriate, but writing messages and asking the client to translate is not an
appropriateapproach.
Gestures, pictures, and play-acting help the client understand.
A)
“We want to test your mother’s urine to make sure she doesn’t have a urinary tract infection.”
B)
“Your mother’s doctor ordered a urine C&S to rule out a UTI.”
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3.
The daughter of an older adult female client has asked the nurse why a urine specimen was
collected from her mother
earlier that morning. How can the nurse best respond to the daughter’s query?
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C)
“We want to do everything we can to get your mother healthy again.”
D)
“Sometimes sick urine can make the whole person sick, and this might be causing her fever.”
Ans: A
Feedback:
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In order to communicate effectively, the nurse needs to avoid the use of jargon or
abbreviations (“C&S”) that are unfamiliar to those outside the health care system. At
the same time, accuracy is important, and vague and “dumbed- down” answers (“we
want to do everything we can,” “sick urine”) are inappropriate.
A)
Ask the care provider to come and assess the client.
B)
Provide the client’s most recent vital signs.
C)
Ask the care provider if he or she is familiar with this client.
D)
Provide the most likely diagnosis of the problem.
Ans: A
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4.
A nurse has drafted an SBAR communication before contacting the primary care provider of a
client whose condition
has worsened suddenly. How should the nurse best conclude this communication?
Feedback:
The final phase of an SBAR communication involves making a recommendation. In
the case of a client whose condition is worsening, this may entail recommending that
the primary care provider come to assess the client. Asking the care provider if he or
she is familiar with the client should be done early in the communication. Providing
assessment data and possible diagnoses are addressed in the background and
assessment sections of the tool.
5.
The nurse has entered a client’s room and observes that the client is hunched over and appears
to be breathing rapidly.
What type of question should the nurse first implement in this interaction?
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A)
A yes/no question
B)
A directing question
C)
An open-ended question
D)
A reflective question
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There are times when yes/no questions are appropriate. In this case, the nurse may
want to ask, “Do you feel short of breath?” or something similar. Directing
questions and reflective questions follow up on earlier communication. An openended question may elicit the necessary assessment data, but a yes/no question
accomplishes this goal more directly.
A)
The nurse should ask appropriate questions to understand the reasons for the client’s silence.
B)
The nurse should apologize for bothering the client, perform necessary assessments efficiently
and leave the room.
C)
The nurse should document the client’s withdrawal and diminished mood in the nurse’s notes.
D)
The nurse should ask the client if he feels afraid or angry.
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6.
The nurse has entered a client’s room after receiving a morning report. The nurse
rapidly assessed the client’s airway, breathing, and circulation and greeted the client
by saying “Good morning.” The client has made no reciprocal response
to the nurse. How should the nurse best respond to the client’s silence?
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Ans: A
Feedback:
Silence can have many meanings, and the nurse should attempt to identify the
meaning of the client’s silence in a tactful manner. Directly asking if the client is
angry or fearful is likely presumptuous and may harm rapport. The nurse should not
make assumptions around the client’s mood nor should the nurse cease to engage
with the client.
A nurse touches a client’s hand to indicate caring and support. What channel of
communication is the nurse using?
A)
Auditory
B)
Visual
C)
Olfactory
D)
Kinesthetic
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Ans: D
The nurse is using a kinesthetic channel of communication. The channel of
communication is the medium the sender has selected to send the message. The
channel might target any of the receiver’s senses. The channels are auditory (spoken
words and cues), visual (sight, observations, and perceptions), and kinesthetic
(touch).
8.
A nurse is educating a home care client on how to administer a topical medication. The client
is watching television
while the nurse is talking. What might be the result of this interaction?
A)
The message will likely be misunderstood.
B)
The stimulus for communication is unclear.
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C)
The receiver will accurately interpret the message.
D)
The communication will be reciprocal.
Ans: A
Feedback:
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Noise, which is a factor that distorts the quality of a message, can interfere with
communication at any point in the process. If the client is watching television, it is
likely that the message from the nurse will be misunderstood.
A)
Intrapersonal
B)
Interpersonal
C)
Organizational
D)
Focused
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9.
The family of a client in a burn unit asks the nurse for information. The nurse sits with the
family and discusses their
concerns. What type of communication is this?
Feedback:
Interpersonal communication occurs among two or more people with a goal to
exchange messages. Nurses spend most of their day communicating with clients,
family members, and health care team members.
10.
Which of the following is an example of nonverbal communication?
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A)
A nurse says, “I am going to help you walk now.”
B)
A nurse presents information to a group of clients.
C)
A client’s face is contorted with pain.
D)
A client asks the nurse for a pain shot.
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Nonverbal communication is the transmission of information without the use of
words. In this situation, the facial contortion is a nonverbal message of pain.
A)
Making constant eye contact with the client
B)
Waving to the client when entering the room
C)
Sighing frequently while providing care
D)
Holding the client’s hand while talking
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11.
A nursing student caring for an unconscious client knows that communication is important
even if the client does not
respond. Which nonverbal action by the nursing student would communicate caring?
Ans: D
Feedback:
Tactile sense is a form of nonverbal communication and is viewed as one of the most
effective nonverbal ways to express feelings of comfort.
12.
Which of the following statements is true of factors that influence communication?
A)
Nurses provide the same information to all clients, regardless of age.
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B)
Men and women have similar communication styles.
C)
Culture and lifestyle influence the communication process.
D)
Distance from a client has little effect on a nurse’s message.
Ans: C
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Culture and lifestyle do influence the communication process; understanding a
client’s culture assists nurses in understanding nonverbal communication and enables
the nurse to deliver accurate care.
A)
The nurse is outside the client’s personal space.
B)
The nurse is in the client’s personal space.
C)
The client does not like the nurse.
D)
The client has concerns about the questions.
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13.
A nurse is sitting near a client while conducting a health history. The client keeps edging away
from the nurse. What
might this mean in terms of personal space?
Ans: B
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Feedback:
Each person has a sense of how much personal or private space is needed and what
distance between individuals is optimum. It is best to take cues from the client; a
client moving backward indicates discomfort with invasion of his or her personal
space.
Why is communication important to the “assessing” step of the nursing process?
A)
The major focus of assessing is to gather information.
B)
Assessing is primarily focused on physical findings.
C)
Assessing involves only nonverbal cues.
D)
Written information is rarely used in assessment.
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The major focus of assessment is to gather information using both verbal and
nonverbal communication forms. Nurses use the written word, the spoken word, and
one-to-one communication with clients. Effective communication techniques, as
well as observational skills, are used extensively during assessment.
15.
A nurse uses the SBAR method to hand off the communication to the health care team. Which
of the following might be
listed under the “B” of the acronym?
A)
Vital signs
B)
Mental status
C)
Client request
D)
Further testing
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Ans: B
Feedback:
SBAR stands for Situation, Background, Assessment, and Recommendations, and
provides a consistent method for hand-off communication that is clear, structured,
and easy to use. Vital signs would fall under the category of situation; mental status:
background; client request: assessment; further testing: recommendations.
What is the goal of the nurse in a helping relationship with a client?
A)
To provide hands-on physical care
B)
To ensure safety while caring for the client
C)
To assist the client to identify and achieve goals
D)
To facilitate the client’s interactions with others
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A helping relationship exists among people who provide and receive assistance in
meeting human needs. When a nurse and a client are involved in a helping
relationship, the nurse assists the client to identify and achieve goals that allow the
client’s human needs to be met.
17.
What action by the nurse will facilitate the helping relationship during the orientation phase?
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A)
Providing assistance to meet activities of daily living
B)
Introducing oneself to the client by name
C)
Designing a specific teaching plan of care
D)
Preparing for termination of the relationship
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In the orientation phase of the helping relationship, the nurse and patient meet and
learn to identify each other by name. It is especially important that the nurse
introduce herself or himself to the patient during this phase.
Which of the nursing roles is primarily performed during the working phase of the helping
relationship?
A)
Educator and counselor
B)
Provider of care
C)
Leader and manager
D)
Researcher
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18.
Ans: A
Feedback:
The nursing roles of educator and counselor are primarily performed during the
working phase of the helping relationship. This is where the nurse’s interpersonal
skills are used to the fullest.
19.
Which term describes a nurse who is sensitive to the client’s feelings, but remains objective
enough to help the client
achieve positive outcomes?
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A)
Competent
B)
Caring
C)
Honest
D)
Empathic
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Empathy is identifying with the way another person feels. An empathic nurse is
sensitive to the client’s feelings and problems, but remains objective enough to help
the client work to attain positive outcomes.
What is the primary focus of communication during the nurse–client relationship?
A)
Time available to the nurse
B)
Nursing activity to be performed
C)
Client and client needs
D)
Environment of the client
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20.
Ans: C
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Communication in the nurse–client relationship should focus on the client and patient
needs, not on the nurse or an activity in which the nurse is engaged.
Which of the following is an example of a closed-ended question or statement?
A)
“How did that make you feel?”
B)
“Did you take those drugs?”
C)
“What medications do you take at home?”
D)
“Describe the type of pain you have.”
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The closed-ended question or statement provides the receiver with limited choices of
possible responses and might often be answered by one or two words, such as “yes”
or “no.” When not used appropriately, closed-ended questions are a barrier to
effective communication.
A)
“Tell me what you are worried about.”
B)
“Have you spoken to your family about your concerns?”
C)
“Do you want to cancel your surgery?”
D)
“Don’t worry, everything will be fine.”
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22.
A client tells the nurse that he is very worried about his surgery. Which of the following
responses by the nurse is a
cliché?
Ans: D
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A cliché is a stereotypical, trite, or pat answer. Most health care clichés suggest there
is no cause for concern, or they often offer false assurance. Their use tends to be
interpreted as a lack of real interest in what has been said.
A)
Using comments that give advice
B)
Using judgmental or belittling language
C)
Using leading questions
D)
Using probing questions
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A nurse tells a client, “Aren’t you going to get out of bed or are you just going to sleep all day
and night?” This is an
example of which of the following barriers to communication?
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Using judgmental comments tends to impose the nurse’s standards on the client. In
this case, the nurse judges the client as being lazy and the nurse’s apparent hostility
could end effective communication.
24.
A nurse is caring for a client who is visually impaired. Which of the following is a
recommended guideline for
communication with this client?
A)
Ease into the room without acknowledging presence until the client can be touched.
B)
Speak in a louder tone of voice to make up for lack of visual cues.
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C)
Explain reason for touching client before doing so.
D)
Keep communication simple and concrete.
Ans: C
Feedback:
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For clients who are visually impaired, the nurse should acknowledge his or her
presence in the client’s room, identify self by name, speak in a normal tone of voice,
explain the reason for touching the client before doing so, and indicate to the client
when the conversation has ended and when leaving the room.
A)
“I myself cannot take insulin injections.”
B)
“Has someone taught you how to take them?”
C)
“You should learn to take injections yourself.”
D)
“Ask the doctor to change the medications.”
Ans: B
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25.
A client has been recently diagnosed with diabetes. He is seen in the emergency room
every day with high blood sugar. The client apologizes to the nurse for bothering
them every day, but he cannot give himself insulin injections. What
should the nurse’s response be?
Feedback:
The nurse should assess whether the client has a knowledge deficit regarding selfinjection. If there is a knowledge deficit, the nurse should educate the client in the
correct method of taking insulin injections. Answer A is a negative reinforcement and
is therefore inappropriate. Demanding that the client learn injection administration is
also inappropriate. Answer D is inappropriate, because the nurse should not offer a
change that cannot be carried out.
A nurse pays a house visit to a client who is on total parenteral nutrition. The client expresses
that he misses enjoying
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food with his family. What is the most appropriate response by the nurse?
A)
Tell me more about how it feels to eat with your family.
B)
You can sit with your family at meal times, even though you don’t eat.
C)
In a few weeks you may be allowed to eat a little; you may enjoy then.
D)
I know that you must be missing your favorite foods.
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The nurse should help the client to verbalize his feelings and cope with aspects of
illness and treatment. Asking open- ended questions is most appropriate as the nurse
encourages the client to express his feelings. The other options block communication
and are not appropriate. Telling the client that he can sit with his family but avoid
eating does not consider the client’s feelings. Informing the client that he will be able
to eat food in a few weeks changes the subject and stops communication. Stating that
the client is missing his favorite dishes devalues the client’s feelings.
A)
Engage the client in a lengthy discussion to strengthen his voice.
B)
Encourage the client to speak quickly while talking.
C)
Repeat what the client has said to verify the meaning.
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27.
A nurse is caring for a client with myasthenia gravis. The client is having difficulty forming
words and his tone is nasal.
Which of the following is an effective communication strategy for this client?
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D)
Nod continuously when the client is talking.
Ans: C
Feedback:
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The client is having a problem forming words and has a nasal tone due to a nerve
involvement that controls speech. For effective communication, the nurse should
repeat and verify whatever the client says. The nurse should ask those questions
which can be answered in a yes or no form. Lengthy discussions may tire the client.
Encouraging the client to speak quickly is inappropriate. Nodding continuously when
the client is talking would not facilitate an effective communication strategy.
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28.
The nurse has engaged the services of an interpreter when interviewing a client who speaks a
language that the nurse
does not understand. The interpreter is functioning in which role during the communication
process?
Sender
B)
Encoder
C)
Receiver
D)
Communication channel
Ans: D
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A)
Feedback:
The interpreter’s role is that of a communication channel. A communication channel
is the medium, the carrier of the message. The interpreter conveys the message sent
by the client to the nurse. The client is the sender and the encoder of the message. The
nurse is the receiver of the message.
29.
A client comes to the clinic complaining of abdominal pain. Which first question would be
most appropriate for the
nurse to ask to facilitate the assessment?
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A)
“Do you have sharp, stabbing pain?”
B)
“Is the pain associated with meals?”
C)
“What activities exaggerate the pain?”
D)
“Does the pain increase on palpation?”
Ans: C
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Feedback:
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“What activities exaggerate the pain?” is an open-ended question, because it gives the
client an opportunity to express feelings and describe the pain. “Do you have sharp,
stabbing pain?”; “Is the pain associated with meals?”; and “Does the pain increase on
palpation?” are questions that can be answered with “Yes” or “No.” These questions
would be helpful later in the assessment to help focus on the client’s statements.
A)
Legal representation to care
B)
Conveyance of information
C)
Assisting in organization of care
D)
Noting the client’s response to
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30.
When documenting client care, the nurse understands that the most important reason for
correct and accurate
documentation is which of the following?
interventions Ans: B
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Feedback:
Documentation of care in the client’s record is most important for communicating
with other health care team members that are involved in the care of the patient.
A)
An incongruent relationship
B)
A confused relationship
C)
A non-therapeutic relationship
D)
An evaluative relationship
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31.
An older adult client who has had a colostomy for over 10 years states, “I won’t need
any teaching about colostomies. I understand how to change the bag and care for my
colostomy, but I’m not sure how to best clean my stoma.” What does
this statement indicate?
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Ans: A
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The client’s two statements are incongruent with each other. This indicates the need for further
education.
32.
Which of the following statements accurately describes the relationship between therapeutic
communication and the
nursing process? Select all that apply.
A)
Effective communication techniques, as well as observational skills, are used extensively
during the assessment step.
B)
Only the written word in the form of a medical record is used during the diagnosing step of the
nursing process.
C)
The implementing step requires communication among the client, nurse, and other team
members to develop
interventions and outcomes.
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D)
Verbal and nonverbal communication are used to educate, counsel, and support clients and
their families during the
implementation phase.
E)
Nurses rely on the verbal and nonverbal cues they receive from their clients to evaluate
whether client objectives have
been achieved.
Ans: A, D, E
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Effective communication techniques, as well as observational skills, are used
extensively during the assessment phase, since the major focus of assessment is to
gather information in both verbal and nonverbal communication forms.
Following the formulation of the nursing diagnoses, the nurse communicates findings
to other nursing professionals through the use of the written and spoken word. The
planning step requires communication among the client, nurse, and other team
members, as mutually agreed-upon outcomes are developed and interventions are
determined. Verbal and nonverbal communication are employed to enhance basic
caregiving measures and to educate, counsel, and support clients and their families
during the implementation phase. Nurses often rely on the verbal and nonverbal cues
they receive from their clients to verify whether client objectives have been achieved.
Because one nurse cannot provide 24- hour coverage for clients, significant
information must be passed on to others through nursing progress notes and care
plans (documentation).
A)
Making formal introductions
B)
Making a contract regarding the relationship
C)
Providing assistance to achieve goals
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33.
A nurse who is discharging a client is terminating the helping relationship. Which of the
following actions might the
nurse perform in this phase? Select all that apply.
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D)
Helping client perform activities of daily living
E)
Examining goals of the relationship to determine their achievement
Ans: E
Feedback:
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In the termination phase, the nurse examines with the client the goals of the helping
relationship for indications of their attainment, or for evidence of progress toward
them. If goals were not attained, the nurse should help the client establish a
relationship with the new nurse. Answers A and B occur in the orientation phase, and
answers C and D occur in the working phase.
A)
Empathy
B)
Sympathy
C)
Trust
D)
Closure
Ans: C
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34.
A nurse tells a client that she will come back in 10 minutes to re-assess the client’s pain. When
the nurse returns in 10
minutes, which aspect of the therapeutic relationship is the nurse developing?
Feedback:
When a nurse repeatedly upholds commitments made to a client, it fosters
foundational trust within the therapeutic relationship. The other options may be part
of the therapeutic relationship, but in this case the nurse’s behavior will instill trust.
35.
Which of the following should the nurse first consider when attempting to become culturally
competent?
A)
Personal cultural beliefs and prejudices
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B)
Understanding the client’s response
C)
Avoiding labeling clients
D)
Treating the client with dignity
Ans: A
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The first step toward cultural competence requires becoming aware of your own personal
cultural beliefs and prejudices.
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Chapter 9, Teaching and Counseling
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1.
A male client age 61 years has been admitted to a medical unit with a diagnosis of pancreatitis
secondary to alcohol use.
Which of the client’s following statements suggests that nurses’ education has resulted in
affective learning?
“I’m starting to see how my lifestyle has caused me to end up here.”
B)
“I understand why they’re not letting me eat anything for the time being.”
C)
“My intravenous drip will keep me from getting dehydrated right now.”
D)
“I can see how things could have been much worse if I hadn’t gotten
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A)
to the hospital when I did.” Ans: A
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Feedback:
The client’s understanding of his contribution to his problem demonstrates a shift in
attitude and feelings that is characteristic of affective learning. Understanding the
treatment, course, and prognosis of his illness are aspects of cognitive learning.
A)
“What changes will you make around your house to reduce the chance of future falls?”
B)
“Do you have any questions about the fall prevention measures that we’ve talked about?”
C)
“In light of what we’ve talked about, why is it important that you remove the throw rugs in
your house?”
D)
“Do you think that the safety measures I taught you are clear and realistic?”
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2.
The nurse has been working with a client for several days during the client’s
recovery from a femoral head fracture. How should a nurse best evaluate whether
client education regarding the prevention of falls in the home has been
effective?
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Feedback:
An open-ended question that requires the client to apply the information that has been
taught is often the most accurate way to evaluate the effectiveness of client education.
Yes/no questions are much less effective (“Do you have any questions?”; “Do you
think that the safety measures I taught you are clear and realistic?”). Asking the client
about the importance of preventing falls does not directly assess what the client will
actually do to prevent falls.
3.
A diabetes nurse educator is teaching a client, newly diagnosed with diabetes, about his
disease process, diet, exercise,
and medications. What is the goal of this education?
A)
To help the client develop self-care abilities
B)
To ensure the client will return for follow-up care
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C)
To facilitate complete recovery from the disease
D)
To implement ordered teaching and counseling
Ans: A
Feedback:
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The basic purpose of educating and counseling is to help clients and families develop
the self-care abilities (knowledge, attitude, skills) needed to maintain and improve
health.
A)
Promoting health
B)
Preventing illness
C)
Restoring health
D)
Facilitating coping
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Ans: D
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4.
A nurse refers a client with a new colostomy to a support group. This nurse is practicing
which of the following aims of
nursing?
Feedback:
Not all clients fully recover from their illness or injury; many clients will need to
learn to cope with permanent health alterations.
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Which of the following is an essential component of the definition of learning?
A)
Increases self-esteem
B)
Decreases stress
C)
Can be measured
D)
Cannot be measured
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Ans: C
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Feedback:
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Learning is the process by which a person acquires or increases knowledge, or
changes behavior in a measurable way, as a result of an experience.
A)
A focus on the immediate application of new material
B)
A need for support to reduce anxiety about new learning
C)
Older students may feel inferior in terms of new learning
D)
All students, regardless of age, learn the same
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6.
A nursing faculty member is teaching a class of second-degree students who have an average
age of 32. What is
important to remember when teaching adult learners?
Ans: A
Feedback:
Adults need to be taught differently. Andragogy, the study of teaching adults, is
based on several principles. One of those is that most adults’ orientation to learning
is that new material should be immediately applicable.
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A)
Use materials developed previously for U.S. citizens.
B)
Use all visual materials when teaching content.
C)
Use a lecture format to teach content with few questions.
D)
Develop written materials in the client’s native language.
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7.
A nurse is designing a teaching program for individuals who have recently immigrated to the
United States from Iraq.
Which of the following considerations is necessary for culturally competent client teaching?
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Ans: D
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With changes in society, nurses are faced with the challenge of teaching clients from
different cultural and ethnic backgrounds. One of the strategies is to develop written
materials in the native language of the client.
Which of the following strategies might a nurse use to increase compliance with education?
A)
Include the client and family as partners.
B)
Use short, simple sentences for all ages.
C)
Provide verbal instruction at all times.
D)
Maintain clear role as the authority.
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8.
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Ans: A
Feedback:
Compliance is facilitated by including the client and family in the education–learning
process. Other strategies include making sure instructions are understandable, using
interactive education methods, and having a strong interpersonal relationship with
clients and their families.
A)
Knowledge Deficit: Infant care
B)
Impaired Health Maintenance
C)
Readiness for Enhanced Parenting
D)
Readiness for Enhanced Coping
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9.
A young mother asks the nurse in a pediatric office for information about safety, diet, and
immunizations for her baby.
Which nursing diagnosis would be appropriate for this client?
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Ans: C
A client who requests information is demonstrating motivation and readiness to learn.
The appropriate nursing diagnosis would be Readiness for Enhanced Parenting.
10.
Developing an education plan is comparable to what other nursing activity?
A)
Documenting in the nurses notes
B)
Formulating a nursing care plan
C)
Performing a complex technical skill
D)
Using a standardized form or format
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Ans: B
Feedback:
Planning for learning involves the development of an education plan. Both education
plans and nursing care plans follow the steps of the nursing process.
A)
Ask other students what should be included in content.
B)
Ask the client what he or she wants to know.
C)
Tell the instructor that this topic hasn’t been covered yet.
D)
Review information available in writing and on the Internet.
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11.
A student is developing an education plan for her assigned client. The student wants to
educate the client on what
symptoms to report after chemotherapy. What would the student need to do first?
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Ans: D
New nurses (and students) usually need to research the subject to be taught to
determine what information exists on the topic. Books, journals, manuals, and Webbased sources may be used to find information.
12.
A mother of a toddler wants to learn how to do CPR. What education strategy would be most
effective in helping her
learn?
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A)
Lecture
B)
Discussion
C)
Demonstration
D)
Discovery
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When a client wants to learn a specific skill, such as CPR, demonstration is an
effective strategy. The client’s learning can be evaluated by return demonstration.
Lecture, discussion, and discovery are not as effective in teaching a skill.
A nurse instructs a client to tell her about the side effects of a medication. What learning
domain is the nurse evaluating?
A)
Affective
B)
Cognitive
C)
Psychomotor
D)
Emotional
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Ans: B
Feedback:
Cognitive learning involves storing and recalling new knowledge in the brain.
Cognitive learning may be evaluated through oral questioning.
14.
When is the best time to evaluate one’s own teaching effectiveness?
A)
During the education session
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B)
Immediately after an education session
C)
1 week after the education session
D)
1 month after the education session
Ans: B
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It is best to evaluate one’s own teaching effectiveness immediately after an education
session by quickly reviewing how one feels the plan was implemented; noting both
strengths and weaknesses helps plan for subsequent sessions.
A)
Praise him for trying.
B)
Tell him that he will have another MI and it will be his own fault.
C)
Tell him that his cigarettes will be taken away if he smokes again.
D)
Ignore the behavior and recommend a behavior modification program.
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15.
A male client age 42 years recovering from a MI is having difficulty following the care plan to
stop smoking and
exercise. What is the nurse’s best response to this client?
Ans: D
Feedback:
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Negative reinforcement (criticism or punishment) is generally ineffective; undesirable
behavior is usually best ignored. Behavior modification programs that reward desired
behaviors and ignore undesired behaviors might be best for this client.
What is the most critical element of documentation of education?
A)
A summary of the education plan
B)
The implementation of the education plan
C)
the client’s need for learning
D)
Evidence that learning has occurred
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16.
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Ans: D
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Documentation of the education–learning process includes a summary of the learning
need, the plan, the implementation of the plan, and the evaluation results. The
evaluative statement is crucial and must show concrete evidence that demonstrates
that learning has occurred. If the desired learning has not occurred, the notes should
indicate how the problem was resolved. It is insufficient to document only what was
taught; the charting must show evidence that the client or significant other has
actually learned the material taught.
17.
What word or phrase best describes an effective counselor?
A)
Technically skilled
B)
Knowledgeable
C)
Practical
D)
Caring
Ans: D
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Feedback:
An effective counselor needs to be a caring individual with the interpersonal skills of
warmth, friendliness, openness, and empathy.
A)
None
B)
Long-term
C)
Short-term
D)
Motivational
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18.
An older adult client is very stressed about who will care for his pets while he is hospitalized
for a fall that caused a
fractured hip. What type of counseling would the nurse conduct?
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Short-term counseling focuses on an immediate problem or concern of the client or
family. Even if it is a relatively minor concern, it needs immediate attention.
19.
A nurse is using motivational interviewing to find out why a client refuses to
participate in the recommended rehabilitation program. Which of the following is an
example of using the skill of reflective listening to help motivate
this client?
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A)
So, you feel that you are not ready to start a program this week…?
B)
Why do you feel that you are not ready to start rehabilitation?
C)
I understand that you are afraid to start rehabilitation; where do you see yourself in a week?
D)
Remember we discussed what needs to be done to get you back on your feet…How do you
feel about getting started?
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Four skills have proved effective in motivational interviewing. These include:
(answer A) reflective listening (restates the client’s response back to him or her),
(answer B) asking open questions (encourages discussion of the reason for making
desired changes), (answer C) affirming (supports the client’s efforts and encourages
further exploration), and (answer D) summarizing (links and reinforces material that
has been discussed).
A)
Proof of compliance with education standards
B)
Client’s response to the health education
C)
Self-administration of medications
D)
Dietary instructions for the client
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20.
At completion of the health education for a client, the nurse documents the details of the
health education in the client’s
medical record. What can be determined by this documentation?
Ans: A
Feedback:
The information about who was taught, what was taught, the education method, and the
evidence of learning is the best proof of compliance with education standards. These
are entered in the client’s medical record. The client’s response to the health education
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cannot be determined by this document. Self-administration of medications and dietary
instructions for the client are not implied from who was taught, what was taught, the
education method, and the evidence of learning.
A)
Cognitive domain
B)
Affective domain
C)
Psychomotor domain
D)
Interpersonal domain
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21.
A client 36 years of age is able to understand the health education when she is given
the opportunity to put theeducation into practice. The nurse helps the client to selfadminister the medication dosage before the client is discharged from the
health care facility. Which domain correctly identifies the client’s learning style?
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The client’s learning style falls into the psychomotor domain, which is a style of
processing that focuses on learning by performing what has been learned. The
cognitive domain is a style of processing information by listening or reading facts
and descriptions. The affective domain is a style of processing, which appeals to a
person’s feelings, beliefs, or values. The interpersonal domain is a style of
processing that focuses on learning through social relationships.
22.
When caring for a client, the nurse gives day-to-day examples to explain certain
points of the health education. The nurse also notes the client’s concentration level
and educates when the client is active. Which category does the client
fall into?
A)
Motivation
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B)
Attention and concentration
C)
Learning readiness
D)
Learning needs
Ans: B
Feedback:
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The client’s attention and concentration affect the duration, delivery, and education
methods employed. It is helpful to observe the client and implement health education
when he or she is most alert and comfortable. This also means involving the client in
an active way by providing examples of day-to-day activities. Learning is optimal
when a person has a purpose for acquiring new information. The client needs to be
motivated to learn new things. Readiness refers to the client’s physical and
psychological well-being. The best education and learning take place when both are
individualized. To be most efficient and personalized, the nurse must gather
pertinent information from the client and determine the client’s needs when learning.
A)
Ask the children to play another game.
B)
Tell the toddler that God punishes children who snatch.
C)
Give the toddler another toy with which to play.
D)
Enlist the aid of the toddler’s parents in education.
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23.
A nurse notices that a toddler is constantly snatching toys from the hands of other
preschool children at the health care facility, placing the toddler and other children at
risk for injury. Which of the following would be a most effective
method for teaching the toddler not to snatch toys?
Ans: D
Feedback:
The nurse should inform the toddler’s parents as to his or her behavior. Since
toddlers and preschoolers are accustomed to learning from and communicating with
their parents, the parents are usually the most effective teachers. Children learn
through play, so using dolls or toys as models can enhance learning. Giving another
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B)
Attention and concentration
toy to the toddler or askingthe children to play another game may not solve the
problem, as the toddler would still want someone else’s toys. Telling the toddler that
God punishes children who snatch is not correct because the nurse is indirectly trying
to scare and threaten the toddler.
To meet accreditation standards regarding client care, a health care facility must show
evidence of what?
A)
Employee satisfaction surveys
B)
Financial accounts and statements
C)
Documentation of indigent care
D)
Client education documentation
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The Joint Commission also has established standards for client education that health
care agencies must meet to receive accreditation.
25.
When providing client education it is essential for the nurse to incorporate what action so that
learning can be
optimized?
A)
Have the clients read material after client education
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B)
Be sure that clients are formally engaged
C)
Include educational strategies that encourage clients to be active participants
D)
Administer tests to evaluate learning
Ans: C
Feedback:
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The teaching–learning relationship is a dynamic, interactive process that involves
active participation from the nurse and client.
A)
Educational levels
B)
Home environment
C)
Infant bonding
D)
Baseline knowledge of these concepts
Ans: D
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26.
The parents of an infant suffering from apnea need to be educated on the apnea monitor and
cardiopulmonary
resuscitation. What should the nurse assess first regarding the parents?
Feedback:
Before educating parents on the apnea monitor and cardiopulmonary resuscitation,
the nurse should determine the parents’ baseline knowledge so that the nurse knows
where to begin. Educational level would be the next assessment in order to plan the
appropriate teaching delivery method.
27.
When the newly diagnosed, insulin-dependent diabetic client tells the nurse that he has never
received instruction on the
administration of injections, an appropriately stated nursing diagnosis for the client is what?
A)
Self-care deficit related to lack of knowledge about injections
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B)
Be sure that clients are formally engaged
B)
Knowledge deficit related to lack of knowledge about injections
C)
Deficient knowledge of injection administration as verbalized by the client, related to the lack
of instruction and
experience
D)
Ineffective health care maintenance related to diabetic instructions
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Ans: C
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Many factors can contribute to deficient knowledge, such as a lack of exposure, lack
of recall, information misinterpretation, cognitive limitations, lack of interest in
learning, and unfamiliarity with information resources.
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28.
A nurse is writing learning outcomes for a client recovering from severe burns. Which of the
following verbs would be
good choices to use when preparing outcomes related to learning how to change dressings?
Select all that apply.
Assembles
B)
Demonstrates
C)
Gives examples
D)
Identifies
E)
Chooses
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A)
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Ans: A, B
Feedback:
Changing dressings falls into the psychomotor domain. “Assembles” and
“demonstrates” are appropriate verbs for outcomes. “Gives examples” and
“identifies” are verbs best used for the cognitive domain. “Chooses” and “values”
relate to the affective domain.
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29.
A nurse educating a new mother on how to bathe her infant uses the acronym TEACH to
maximize the effectiveness of
the education plan. Which of the following are guidelines based on this acronym? Select all
that apply.
Tune out the individual client.
B)
Edit client information.
C)
Act on every teaching moment.
D)
Always refer a client to counseling.
E)
Clarify often.
Ans: B, C, E
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A)
Feedback:
To maximize the effectiveness of patient education, the nurse should use the acronym
TEACH — T: tune into the client, E: edit client information, A: act on every teaching
moment, C: clarify often, H: honor the client as a partner in the education process.
30.
The National Patient Safety Foundation recently collaborated with the Partnership for
Clear Health Communication (2007) to create awareness of the need for improved
health literacy and developed the Ask Me 3 tool. Which of the
following is an Ask Me 3 question? Select all that apply.
A)
Who will be my health care provider?
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B)
What is my main problem?
C)
What do I need to do?
D)
Where will I get help?
E)
Why is it important for me to do this?
Ans: B, C, E
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Ask Me 3 questions are: What is my main problem? What do I need to do? Why is it
important for me to do this?
According to Rosenstock, which of the following are health beliefs critical for client
motivation? Select all that apply.
A)
Clients view themselves as susceptible to the disease in question.
B)
Clients view the disease as a serious threat.
C)
Clients believe there are actions they can take to reduce the probability of contracting the
disease.
D)
Clients believe the threat of taking these actions is greater than the disease itself.
E)
Patients view themselves as victims of the disease in question.
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31.
Ans: A, B, C
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Feedback:
A client’s health beliefs can have great influence on motivation. The health belief
model identifies several health beliefs as critical for client motivation (Rosenstock,
1974). Motivation is enhanced when clients view themselves as susceptible to the
disease in question; when clients view the disease as a serious threat; when clients
believe there are actions they can take to reduce the probability of contracting the
disease; when clients believe the threat of taking these actions is not as great as the
disease itself.
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32.
A nurse is educating an elderly client with diabetes and his family members about the
importance of a nutritious diet.
The nurse knows that client education promotes which of the following purposes? Select all
that apply.
Helps the nurse to restore optimal health in the client
B)
Helps the client to cope with alterations in health status
C)
Helps the nurse to be more aware of the client’s health
D)
Helps the nurse to diagnose the client’s illness early
E)
Helps the nurse to be well-informed about the client’s care
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A)
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Feedback:
Nurses are involved in client education to promote wellness (primary prevention),
prevent or diagnose illness early (secondary prevention), restore optimal health and
function if illness has occurred (tertiary prevention), and assist clients and families to
cope with alterations in health status. Simply being knowledgeable about the client’s
health status and care is not enough. Nurses must know the education and learning
process and know how best to include the client’s family in the process.
33.
A nurse in a neighborhood clinic is conducting educational sessions on weight loss. What aim
of nursing is met by these
educational programs?
A)
Practicing advocacy
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Preventing illness
C)
Restoring health
D)
Facilitating coping
E)
Maintaining and promoting health
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Ans: B, C, E
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If this education is directed toward those who are healthy, weight loss information can
help maintain health andprevent illness. If this education is used in those already ill
(hypertension, diabetes), weight loss can restore health. The nurse is not practicing
advocacy or facilitating coping by providing weight loss education.
What client characteristic is important to assess when using the health belief model as the
framework for teaching?
A)
Developmental level
B)
Source of information
C)
Motivation to learn
D)
Family
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34.
support Ans:
C
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Feedback:
When assessing a client’s learning readiness, it is important to consider his or her
motivation. Motivation is influenced by an individual’s health beliefs and plays a
key role in the health belief model. Motivation encourages the client to adopt health
promotion and disease prevention actions.
35.
A nurse is working with an older adult client, educating the client on how to
ambulate with the aid of a walker. The nurse notes that the client appears to lack the
motivation to learn how to use device. The client states, “I’m just too old to
learn.” Which of the following would be most appropriate for the nurse to do to motivate this
client?
Tell the client how to move the walker as he ambulates.
B)
Explain how the walker supports the client’s lower extremities
C)
Fully discuss the rationale for using the walker.
D)
Describe how the walker can improve the client’s quality of life.
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A)
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Ans: D
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Motivating the older adult client can be done by showing the client how the new
knowledge will improve his quality of life, regardless of how long that may be. It
will also demonstrate how the new knowledge could improve the client’s level of
independence. Although demonstrating the use of the walker and explaining how the
walker assists with ambulation (and the rationale for its use) can be used to educate
the client, these actions would not promote motivation for the client to learn.
Chapter 10, Leading, Managing and Care Delegating
1.
Which of the following nursing care tasks is acceptable for a graduate nurse to delegate to
unlicensed assistive personnel
(UAP)?
A)
Assisting a client with ambulation
B)
Evaluation of nursing care delivered to a client
C)
Initial and ongoing assessments
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Feedback:
D)
Development of a client teaching plan
Ans: A
Feedback:
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Tasks that should be performed by a registered nurse include initial and ongoing
assessments, determining nursing diagnoses, plan of care, evaluation of client
progress, evaluation of the nursing care delivered to the patient, supervision and
education of nursing personnel, and client education. Tasks such as ambulation,
assistance with meals and hygiene, and obtaining vital signs are acceptable tasks for a
UAP to perform.
A)
Self-evaluation skills
B)
Communication skills
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2.
Nurses with varying levels of experience possess leadership skills. A graduate nurse
walks out of the nurse manager’s office after a meeting. The graduate nurse reflects
on the positive and negative feedback that she received from the manager regarding
her three months working on the unit. What nursing leadership skill is best illustrated
by the graduate
nurse in this scenario?
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C)
Problem-solving skills
D)
Management skills
Ans: A
Feedback:
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Self-evaluation skills incorporate the ability to assess honestly one’s effectiveness, to
accept both praise and criticism, and to direct personal professional growth.
Communication skills demonstrate the ability to establish trusting interpersonal
relationships with clients, peers, subordinates, and superiors to maximize goal
achievement. Problem- solving skills include the ability to analyze all sides of a
problem, to suspend judgment, to explore multiple options, and to work toward a
creative solution. Management skills are the ability to direct others toward goal
achievement.
What type of leadership can a graduate nurse working in a magnet hospital expect?
A)
Democratic
B)
Autocratic
C)
Situational
D)
Quantum
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Ans: A
Feedback:
Working in a magnet hospital can maximize the potential of new graduates who prefer
democratic leadership.
4.
The nurse is having an exceptionally busy shift on an obstetrical unit. Which of the following
tasks is the nurse justified
in delegating to an unlicensed care provider?
A)
Emptying a client’s Foley catheter bag and reporting the volume to the nurse
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B)
Helping a first-time mother achieve a good latch when breast-feeding her infant
C)
Assessing the size and quantity of clots that are in a client’s bedpan and informing the nurse
D)
Giving an anti-inflammatory to a client who is eight hours postdelivery
Ans: A
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Emptying a Foley catheter bag and reporting the volume is within the scope of an
unlicensed care provider. Assistance with breast-feeding, assessments, and
medication administration are not tasks that should be delegating to anyone but an
RN.
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The nurse has just graduated with a Bachelor of Science in Nursing and is eager to find a
mentor at this early stage in her
career. Which of the following individuals is most likely to be an appropriate mentor for the
nurse?
An experienced nurse who was a preceptor in a previous clinical placement
B)
The nurse educator on the hospital unit where the novice nurse has been hired
C)
A colleague who graduated with honors at the same time as the novice nurse.
D)
The unit manager who the novice nurse.
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A)
Ans: A
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A person who demonstrates positive qualities and who possesses more experience is
often a good choice to be a nurse’s mentor. A person in formal authority or oversight,
such as the unit educator or manager, is a less ideal choice, and a peer is not normally
an ideal choice of mentor.
A)
Physical stamina
B)
Physical attractiveness
C)
Flexibility
D)
Independence
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6.
A senior student has been elected president of the Student Nurses Association. Which of the
following qualities is
essential to being a nursing leader?
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Flexibility is a must for all nurse leaders. The needs of clients, families, and the
nursing team can change from minute to minute. Leaders of nursing organizations
must also demonstrate the characteristics of a nursing leader.
7.
Which type of skills is not needed for nursing leadership?
A)
Communication skills
B)
Technical skills
C)
Problem-solving skills
D)
Self-evaluation skills
Ans: B
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The four basic types of skills needed for nursing leadership are communication,
problem solving, management, and self- evaluation. Technical skills are important to
other nursing roles, but are not leadership skills.
Communication skills
B)
Problem-solving skills
C)
Management skills
D)
Self-evaluation skills
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8.
A nurse strives to establish trusting interpersonal relationships with clients, peers,
subordinates, and superiors to
facilitate goal achievement and personal growth of all participants. Which type of skills is this
nurse demonstrating?
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Communication skills involve the ability to establish trusting interpersonal
relationships with clients, peers, subordinates, and superiors to maximize goal
achievement and enhance the personal growth. Problem-solving skills refer to the
ability to analyze all sides of a problem, to suspend judgment, to explore multiple
options, and to work toward a creative solution. Management skills pertain to the
ability to direct others toward goal achievement. Self- evaluation skills involve the
ability to assess honestly one’s effectiveness, to accept both praise and criticism, and
to direct personal professional growth and development.
9.
A nurse manager makes all of the decisions for staff activities. What type of leadership is
demonstrated by this action?
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A)
Democratic
B)
Self-governance
C)
Laissez-faire
D)
Autocratic
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Autocratic leadership involves the leader assuming complete control over the
decisions and activities of the group. An extremely autocratic leader might make all
decisions for workers without considering their ideas or feelings.
What type of leader shares decisions and activities with group participants?
A)
Democratic
B)
Autocratic
C)
Laissez-faire
D)
Situational
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10.
Ans: A
Feedback:
Democratic leadership, also called participative leadership, is characterized by
equality among the leader and other participants. Decisions and activities are shared.
11.
A nurse leader is described as charismatic, motivational, and passionate. Communications are
open and honest, and the
nurse is willing to take risks. What type of leadership is the nurse practicing?
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A)
Democratic
B)
Autocratic
C)
Quantum
D)
Transformational
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Transformational leaders are often described as charismatic, challenging, and
passionate about their vision. They communicate openly and honestly, show concern
for others, and are willing to take risks.
A nurse is described as a “quantum leader.” Which action characterizes this type of
leadership?
A)
A nurse conducts a blind survey to evaluate her leadership skills.
B)
A nurse relinquishes power to a group deciding hospital policy.
C)
A nurse makes policy decisions for coworkers without consulting them.
D)
A nurse sticks to the “tried and true” methods when implementing client care.
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12.
Ans: A
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Quantum leaders must have excellent communication skills, encourage personal
critiques, and challenge current ways of thinking and doing. A nurse who relinquishes
power to a group to make decisions is using laissez-faire leadership. A nurse making
decisions for coworkers without considering their feelings is an autocratic leader.
When comparing team nursing with functional nursing, what characteristic is found?
A)
Team nursing is very similar to functional nursing.
B)
Team nursing focuses on individual client care.
C)
Functional nursing has a stronger focus on the client.
D)
Functional nursing is based on total client care.
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In team nursing, a registered nurse and other caregivers provide care to a designated
group of clients for a given shift. Team nursing modifies the depersonalized approach
of functional nursing and focuses on individual client care.
A)
Reflective
B)
Analytical
C)
Worldly
D)
Collaborative
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14.
A nurse believes in listening to clients and coworkers more than talking to them, allowing
more personal control for all
involved. This is a quality of which of the following managerial mindsets?
Ans: D
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The collaborative mindset involves listening more than talking, and allowing people
to take initiative and control their own work. The reflective mindset allows managers
to mentally digest experiences and reflect on them in a different way. The analytical
mindset encourages introspection so that one can recognize biases and see things in a
unique way. This facilitates a change in course and movement toward resolution of
problems. The worldly mindset recognizes cultures and contexts or “seeing
differently out to reflect differently in.”
In which of the following conflict resolution strategies is the conflict rarely resolved?
A)
Collaborating
B)
Compromising
C)
Competing
D)
Smoothing
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Smoothing is an effort to complement the other party and focus on agreement rather
than disagreement, thus reducing the emotion in the conflict. The original conflict is
rarely resolved with this technique.
16.
In Lewin’s classic theory of change, what happens during unfreezing?
A)
Planning is conducted.
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B)
Change is initiated.
C)
Change becomes operational.
D)
The need for change is recognized.
Ans: D
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In Lewin’s change theory, during unfreezing the need for change is recognized.
Unfreezing does not include planning, initiating, or operationalizing change.
A)
All of the alternative solutions are implemented.
B)
A course of action is chosen from among the alternatives.
C)
The effects of the change are evaluated.
D)
The change is stabilized and established.
Ans: B
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17.
Planned change is a purposeful, systematic effort to alter or bring about change. What occurs
next after alternative
solutions to a problem are determined and analyzed?
Feedback:
After determining and analyzing alternative solutions to a problem, select a course of
action from the possible alternatives. It is best to avoid initiating too many courses of
action and thereby dissipating resources and energy.
18.
In general, how do most people view change?
A)
By how it affects the cohesiveness of the group
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B)
By how much it will cost in time and resources
C)
By how they are affected personally
D)
By how it will affect others on the staff
Ans: C
Feedback:
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In general, people view change in terms of how they are affected personally.
Examples include threats to self-esteem, amount of work required, and effect on
social relationships.
A)
Tell the staff that if they don’t like it, they can quit.
B)
Implement change rapidly and all at once.
C)
Encourage open communication and feedback.
D)
Let the staff know that the change is mandated.
Ans: C
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19.
A nurse manager has encountered resistance to a planned change. What is one way the nurse
can overcome the
resistance?
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Providing opportunities for open communication and feedback is one way to overcome
resistance to change.
Which of the following statements accurately describes the use of power by change agents?
A)
They know that power comes from one source—management.
B)
When introducing change they do not enlist the support of key power players.
C)
They are often accomplished professional women.
D)
They do not recognize their own strengths and weaknesses.
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Power,the ability to influence others to achieve a desired effect, has many sources.
When introducing change, it is helpful to recognize and enlist the support of key
power players who can then encourage others to become involved. Women are
accomplished professionals and occupy powerful leadership positions in
corporations, health care organizations, and political arenas. Nursing leaders
recognize the strengths and limitations of their own power and encourage others to
develop and use power constructively.
21.
A nurse working on leadership skills should keep in mind which of the following accurate
statements regarding leaders?
A)
People are born leaders.
B)
Leadership should be approached quickly.
C)
Leaders develop leadership skills in undefined situations.
D)
All nurse leaders began as inexperienced nurses.
Ans: D
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Feedback:
Leadership should be approached like any other new role or skill: slowly and
carefully. Nursing students and beginning nurses should be prepared with all of the
necessary tools or skills before attempting the new role. Initially, nurses develop
leadership skills in well-defined clinical situations. With each experience, growth
occurs and leadership is strengthened. All nurse managers, nurse administrators, and
nursing leaders also began as inexperienced nurses.
A)
Nursing care of the individual client
B)
Demonstration of selected critical skills
C)
Ability to be a follower rather than a leader
D)
Nursing care of groups of clients
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22.
A student nurse has just graduated with a baccalaureate degree in nursing. What type of
nursing leadership will this
nurse be expected to provide?
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Ans: A
New graduates have leadership responsibilities when they begin nursing. Nursing
leadership begins with nursing care of the individual client.
23.
A nurse is considering the delegation of administering medications to an unskilled assistant.
What is the first question
the nurse must ask herself before doing so?
A)
Has the assistant been trained to perform the task?
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B)
Have I evaluated the client’s response to this task?
C)
Is the delegated task permitted by law?
D)
Is appropriate supervision available?
Ans: C
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The first question the nurse should always consider before delegating a task is “Is the
delegated task permitted by law?” In this case, it would not be, and the task
(administering medications) would not be delegated.
A)
It is the nursing profession that determines the scope of nursing practice.
B)
It is the RN who defines and supervises the education, training, and use of any unlicensed
assistant roles.
C)
It is the assigned NAP who is responsible and accountable for his or her nursing practice.
D)
It is the purpose of the RN to work in a supportive role to the assistive personnel.
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24.
The ANA, which is committed to monitoring the regulation, education, and use of NAPs,
recommends adherence to
which one of the following principles?
Ans: A
Feedback:
It is the nursing profession that determines the scope of nursing practice, and defines
and supervises the education, training, and use of any unlicensed assistant roles
involved in providing direct nursing care. It is the registered nurse who is
responsible and accountable for nursing practice, and who supervises any assistant
involved in providing direct client care. It is the purpose of assistive personnel to
work in a supportive role to the registered nurse, carrying out tasks that enable the
professional nurse to concentrate on caring for the client.
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25.
Which of the following is a characteristic of mentorship?
A)
It is a paid position to orient new nurses to the workplace.
B)
It involves membership in a professional organization.
C)
It is a link to a protégé with common interests.
D)
It is not encouraged in health care settings
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Mentorship is a relationship in which an experienced individual (the mentor) advises
and assists a less experienced individual (protégé). This is an effective way of easing
a new nurse into leadership responsibilities. Mentors link with protégés by common
interest and provide support, information, and network links. The relationship does
not include financial reward. An alternative model is preceptorship. The preceptor
(experienced nurse) is selected (and generally paid) to introduce an employee to new
responsibilities through education and guidance.
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26.
A nurse manager has directed a registered nurse who is out of school for one year to become a
member of the
institution’s policy and procedure committee. A goal in the nurse manager’s delegation is to
assist the nurse to what?
A)
Be involved in the hospital
B)
Be confident in employment
C)
Grow in her profession
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D)
Understand the hospital setting
Ans: C
Feedback:
Delegation of activities to staff members will assist them to grow and become more
committed to their organization.
A)
Explain the proposed changes only to the managers of the people involved.
B)
Whenever possible, use technical language to describe the changes.
C)
List the advantages of the proposed change for members of the group.
D)
Avoid relating the change to the group’s existing beliefs and values.
E)
If possible, introduce change gradually.
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27.
Which of the following statements accurately describes recommended guidelines for
overcoming resistance to change?
Select all that apply.
Feedback:
To overcome resistance to change, the nurse should explain the proposed change to
all affected people in simple, concise language; list the advantages of the proposed
change, both for the individual and for members of the group; relate the proposed
change to the person’s (or group’s) existing beliefs and values; if possible, introduce
change gradually; provide incentives for commitment to change such as money,
status, time off, or a better working environment.
28.
A nurse is attempting to change the method for documenting client care in a hospital setting.
Which of the following
should be considered before planning change? Select all that apply.
A)
What is amenable to change?
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B)
How does the group function as a unit?
C)
Is the group ready for change?
D)
Are the changes major or minor?
E)
How can I keep from changing again?
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Before planning to make a change, a nurse manager should consider the following;
What is amenable to change? Considering this question might reveal a behavior not
amenable to change. How does the group function as a unit? Is the person or group
ready for change and, if so, at what rate can that change be expected to be accepted?
Are the changes major or minor? A series of small changes might be more easily
accomplished than one large, dramatic change. Change is inevitable; a more
appropriate question to ask is how often this change needs to be evaluated.
A)
Philosophical
B)
Task-oriented
C)
Charismatic
D)
Dynamic
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29.
A head nurse assumes the leadership role when directing and supervising coworkers. Which of
the following are
attributes of a leader? Select all that apply.
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E)
Intimidating
Ans: A, C, D
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Leadership involves philosophy, perception, and judgment whereas management
tasks are the core of the management role. Leaders need to be comfortable with
themselves (i.e., have a positive self-image) and present themselves as role models
for followers. Ideally, they also have a vision that energizes the group and brings
forth the best efforts of members. Leaders may be charismatic, dynamic, enthusiastic,
poised, confident, and self-directed.
A)
Democratic
B)
Laissez-faire
C)
Autocratic
D)
Transformational
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30.
The nurse is caring for a client who had a sudden episode of vomiting, which
produced 900 mL of frank blood. The nurse directed and delegated to colleagues in
order to notify the physician. She started intravenous fluids, and provided physical
and emotional support for the client. Different situations call for different leadership
styles. Which of the
following leadership styles did the nurse display in this situation?
Ans: C
Feedback:
Autocratic leadership involves the leader assuming complete control. Democratic
leadership displays a sense of equality among the leader and other participants. With
laissez-faire leadership, the leader relinquishes power to the group.
Transformational leaders create intellectually stimulating practice environments and
challenge themselves and others to grow personally and professionally, and to learn.
The nurse is a manager on an orthopedic unit. The unit changed to a new computer
documentation system three days ago. One of the night nurses has called in sick
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A)
Feel threatened
B)
Fear increased responsibility
C)
Lack of understanding
D)
See no benefits to the change
E)
Dislike hospital chief officer
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31.
every shift since the new system started. The nursing manager is aware that this
situation has to do with resistance to change. Which of the following are common
reasons why people resist
change? Choose all that apply.
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The most common reasons people resist change are threat to self, lack of
understanding, fear of increased responsibility, envisioning a lack of benefits to the
change, and being unable to tolerate working in a state of flux. Dislike of the
hospital CEO is not a common reason to resist change.
A)
Identify priorities for the day.
B)
Evaluate time management at the end of the day.
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32.
The nursing student is working to improve his time management. Which of the following
would assist the nursing
student in accomplishing his goal? Choose all that apply.
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C)
Establish a reasonable time line.
D)
Plan to arrive right at start of shift.
E)
Plan on his cohorts helping him
Ans: A, B, C
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Establish goals and priorities for each day. The nurse should identify what needs to be
accomplished each day, differentiating need to do from nice to do tasks. Then nurse
should establish a time line so that it is clearly evident when he or she is falling
behind schedule, in time to correct it. The nurse should evaluate success or failure
and use the results to plan the next day ‘s time management. The nurse should plan to
arrive at least 15 minutes or more before the start of shift so that he or she can be
prepared to receive change of shift report. Then nurse should plan time to assist his
cohorts instead of them helping him. The cohorts may be too busy to assist or may
need assistance themselves.
A)
Constant and predictable
B)
Dynamic and constantly unfolding
C)
Evolving very slowly
D)
An entity needing planning
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33.
During a staff meeting, the nurse is discussing new quantum leadership. The nurse explains
that in this type of
leadership change is viewed as which of the following?
Ans: B
Feedback:
We are in a difficult transition period between the old and the new age. In the old
age, change was viewed as an entity to be planned, carefully managed, and accepted.
In the new quantum age, change is conceived as dynamic, ever-present, and
continually unfolding.
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Which of the following tasks could the nurse safely delegate to unlicensed assistive personnel?
A)
An initial assessment of a client
B)
Determination of a nursing diagnosis
C)
Evaluation of client progress
D)
Documentation of client’s I+O on a flow sheet
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Nursing care or tasks that should never be delegated except to another RN include
(Ayers & Montgomery, 2008) the following: the initial and ongoing nursing
assessment of the client and his or her nursing care needs; the determination of the
nursing diagnosis, nursing care plan, evaluation of the client’s progress in relation to
care plan, and evaluation of the nursing care delivered to the client; the supervision
and education of nursing personnel; client education that requires an assessment of
the client and his or her education needs; and any other nursing intervention that
requires professional nursing knowledge, judgment, and/or skill.
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There is a perception in a long-term care facility that the older adult residents are
experiencing falls more often than in the past. An audit of incident reports has
confirmed this, and the nursing leadership has recognized the need to make changes
to reduce the incidence of falls. How should the leaders proceed with this planned
change? Place the following steps in the correct order.
35.
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Implement the change in nursing practice.
2.
Choose a new protocol that is likely to reduce falls.
3.
Take measures to ensure that nursing practice does not revert.
4.
Determine and analyze different solutions to the problem.
5.
Develop a plan for implementing the change.
B)
1, 3, 2, 4, 5
C)
5, 1, 2,, 3, 4
D)
4, 2, 5, 1, 3
E)
3, 1, 4, 5, 2
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The eight-step program of planned change is similar to the nursing process of
assessment, diagnosis, planning, implementation, and evaluation. After this process,
measures are taken to ensure that the change is stabilized and made permanent.
Chapter 11, The Health Care Delivery System
1.
Which of the following clients is the most appropriate candidate for receiving outpatient care?
A)
A client whose complaints of irregular bowel movements have necessitated a colonoscopy
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B)
A woman who has previously borne two children and is entering the second stage of labor
C)
A man who is receiving treatment for sepsis after his blood cultures came back positive
D)
A client with a history of depression who is currently expressing suicidal ideation
Ans: A
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Outpatient services are appropriate for clients who are medically stable but who
require diagnostic testing, such as a colonoscopy. Clients in active labor and clients
who are actively septic or suicidal require close monitoring and frequent
interventions, which can only be safely provided on an inpatient basis.
A)
A rural health center
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2.
After many years of advanced practice nursing, a nurse has recently enrolled in a
nurse practitioner program. This nurse has been attracted to the program by the
potential to provide primary care for clients after graduation, an opportunity that
is most likely to exist in which of the following settings?
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B)
A long-term care facility
C)
A university hospital
D)
A community hospital
Ans: A
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Many rural health centers employ few health care providers, and primary care is often
provided by a nurse practitioner (NP). A nurse practitioner may provide care in a
long-term care facility or hospital, but in these settings, the NP is less likely to be the
provider of primary care to clients.
Which of the following phrases best describes hospitals today?
A)
Focus on chronic illnesses
B)
Focus on acute care needs
C)
Primary care centers
D)
Voluntary agencies
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Hospitals have become acute care providers for people who are too ill to care for
themselves at home, who are severely injured, who require surgery or complicated
treatment, or who are having babies. Hospitals rarely focus on chronic illnesses, and
they are not primary care centers. Hospitals are not classified as voluntary agencies.
4.
A man is scheduled for hospital outpatient surgery. He tells the nurse, “I don’t know what that
word, outpatient, means.”
How would the nurse respond?
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A)
“It means you will have surgery in the hospital and stay for 2 days.”
B)
“It means the surgeon will come to your home to do the surgery.”
C)
“Why would you ask such a question? Don’t worry about it.”
D)
“You will have surgery and go home that same day.”
Ans: D
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In addition to providing acute care, hospitals have many services for outpatients
(those who require health care but do not need to stay in the facility). Clients who
have outpatient surgery have the procedure, return to their hospital room for
recovery, and then are discharged home on the same day.
A)
Hospital
B)
Physician’s office
C)
Ambulatory center
D)
Long-term care
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5.
A nurse in a walk-in health care setting provides technical services (e.g.,
administering medications), determines the priority of care needs, and provides client
teaching on all aspects of care. Which of the following terms best describes
this type of health care setting?
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Ans: C
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Nurses in ambulatory care centers (walk-in clinics) provide technical services (e.g.,
administering medications), determine the priority of care needs, and provide
teaching about all aspects of care. Nurses employed in hospitals have many roles,
including manager of other members of the health care team providing client care,
administrator, nurse practitioner, clinical nurse specialist, patient educator, in-service
educator, and researcher. In physician’s offices, advanced practice registered nurses
(APRNs), nurse practitioners, midwives, or clinical nurse specialists work
independently or collaboratively with physicians to make assessments and care for
clients who require health maintenance or health promotion activities. Long-term
care provides medical and nonmedical care for people with chronic illnesses or
disabilities.
A)
Provide all care and services
B)
Maintain a clean home environment
C)
Advise clients on financial matters
D)
Collaborate with other care providers
Ans: D
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6.
Nurses who are employed in home care have a variety of responsibilities. Which of the
following is one of those
responsibilities?
Feedback:
Nurses who provide care in the home make assessments, provide physical care,
administer medications, teach, and support family members. They also collaborate
with other health care providers in providing care and services. Home care nurses do
not provide all care and services, maintain a clean home environment, or advise
clients on financial matters.
7.
Which of the following is true of long-term care facilities?
A)
They provide care only to older adults.
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Ans: C
B)
They provide care for homeless adults.
C)
They provide care to people of any age.
D)
They provide care only for people with dementia.
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Ans: C
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Long-term care facilities provide health care, and help with the activities of daily
living, for people of any age who are physically or mentally unable to care for
themselves independently. They do not provide care only to older adults or those
with dementia, although they do care for those populations as well as others. They do
not provide care to homeless persons.
A)
A community health nurse
B)
An outside consultant
C)
A teacher
D)
The school nurse
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8.
A grade school is preparing a series of classes on the dangers of smoking. Who would be most
likely to teach the
classes?
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Ans: D
Feedback:
School nurses provide many different services, including maintaining immunization
records, providing emergency care, administering prescribed medications, conducting
routine screenings, conducting health assessments, and teaching for health promotion
(e.g., the dangers of smoking). Although any of the other choices may provide
teaching, it is the nurse who primarily provides health-related teaching.
A)
Primary care
B)
Respite care
C)
Bereavement care
D)
Palliative care
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9.
An elderly woman has total care of her husband, who suffers from debilitative
rheumatoid arthritis. The couple voices concern over the pain and stress associated
with the condition. What type of care might the nurse suggest to help the
couple?
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Ans: D
The goal of palliative care is relief from the symptoms, pain, and stress of a serious
illness, and to improve the quality of life for both the client and the family. The main
purpose of respite care is to give the primary caregiver some time away from the
responsibilities of day-to-day care. Primary care is found in acute care settings and
physicians’ offices.
Bereavement care is provided to families following the death of a family member.
10.
What population do hospice nurses provide with care?
A)
Those requiring care to improve health
B)
Children with chronic illnesses
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Ans: D
C)
Dying persons and their loved ones
D)
Older adults requiring long-term care
Ans: C
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Hospice is a program of palliative and supportive services providing physical,
psychological, social, and spiritual care for dying persons, their families, and other
loved ones. Hospice nurses do not implement care to improve health, focus on
children with chronic illnesses, or care for older adults in long-term care.
Who provides physicians with the authority to admit and provide care to clients requiring
hospitalization?
A)
The health care institution itself
B)
Board of Healing Arts
C)
American Medical Association
D)
State Board of Nursing
Ans: A
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11.
Feedback:
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Physicians are granted the authority to admit clients to a health care agency or
institution, and to provide care in that setting by the health care agency or institution
itself. They are licensed to practice medicine by a state medical board, not a state
board of nursing or a board of healing arts.
A)
Physical therapist
B)
Speech therapist
C)
Social worker
D)
Respiratory therapist
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12.
After a stroke, a client is having difficulty swallowing. The nurse may make a referral to what
member of the health care
team?
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In addition to providing services to improve oral communication, a speech therapist
may also diagnose and treat swallowing problems in clients who have had a head
injury or stroke. A physical therapist assists with musculoskeletal and neurological
impairments, a social worker is educated to help clients with economic and social
issues, and a respiratory therapist provides treatments to improve breathing.
13.
Medicare uses a prospective payment plan based on diagnosis-related groups (DRGs). What
are DRGs?
A)
Locally supported health care financing, usually by donations
B)
A public assistance program for low-income individuals
C)
Predetermined payment for services based on medical diagnoses
D)
A private insurance plan for subscribers who pay a copayment
Ans: C
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Feedback:
Medicare, based on DRGs, pays a hospital a fixed amount that is predetermined by
the medical diagnosis or specific treatment rather than by the actual cost of
hospitalization and care. This plan was put into effect in an effort to control rising
health care costs. It is not supported by donations; it is not a public assistance
program or a private insurance plan.
A)
The insurance company pays all or most of the costs.
B)
The family of the client is required to pay costs.
C)
The client gets the bill and pays out-of-pocket costs.
D)
Medicare and Medicaid will pay most of the costs.
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14.
A client has a private insurance policy that pays for most health care costs and services. Why
is this plan called a thirdparty payer?
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Insurance for health care may be financed through private insurance, in which
members pay a monthly premium. These plans are called third-party payers, because
the insurance company pays all or most of the cost of care.
15.
A person receiving health care insurance from his employer knows that he should
check the approved list of contracted health care providers before seeking services, in
order to receive them at a lower cost. What type of insurance is most
likely involved?
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A)
Medicaid
B)
Preferred provider organization
C)
Health maintenance organization
D)
Long-term care insurance
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Preferred provider organizations (PPOs) allow a third-party payer (agencies that pay
health care providers for services provided to individuals, such as a health insurance
company) to contract with a group of health care providers to provide services at a
lower fee in return for prompt payment and a guaranteed volume of clients and
services. Although clients are encouraged to use specific providers, they may also
seek care outside the panel without referral by paying additional out-of-pocket
expenses.
What is the primary focus of health care today?
A)
Care of acute illnesses
B)
Care of chronic illnesses
C)
Health promotion
D)
Health restoration
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16.
Ans: C
Feedback:
In the past, health care focused on the treatment of illnesses rather than prevention
through health promotion, because preventive strategies were not covered by health
insurance. Health awareness and the desire to be involved in one’s own health care
have strongly influenced the delivery of health care services in our society.
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What is one way in which nurses can help shape health care reform?
A)
Do their job and do it well
B)
Refuse to participate in organizations
C)
Support legislation to improve care
D)
Become a member of a support group
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There are many ways in which nurses can help shape health care reform, including
supporting legislation to improve care. Nurses are expected to do their job well.
Refusing to participate in organizations and/or becoming a member of a support
group will not help shape health care reform.
Which of the following health care insurance programs is most suitable for a client 68 years of
age?
A)
Medicaid
B)
Medicare
C)
Capitation
D)
AmeriCare
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18.
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Ans: B
Feedback:
Medicare is a federal program that finances health care costs of persons 65 years and
older, permanently disabled workers of any age and their dependents, and those with
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end-stage renal disease. The system is funded primarily through withholdings from an
employed person’s income. Capitation is a reimbursement strategy in managed care
organizations. AmeriCare is a type of private insurance. Capitation and AmeriCare
are not the preferred providers for the client, considering the client’s old age.
Medicaid is a federal program that is operated by the states, and each state decides
who is eligible and the scope of health services offered. In Medicaid, eligibility may
be decided by the state, which is not the case in Medicare.
A)
Acute care
B)
Primary care
C)
Hospice
D)
Rehabilitation
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19.
Nurses who assist clients to deal holistically with their health care needs at the end of their
lives work primarily in which
health care delivery system?
Feedback:
The opportunity to help people maintain their ability to remain at home and deal
holistically with their health and family needs at the end of their lives is home health
hospice care.
20.
What is one of the most significant trends in health care today?
A)
Increased length of hospital stays
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B)
Shift from hospitals to community-based care
C)
Emphasis on disease management
D)
Narrowing of the areas for nursing practice
Ans: B
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The shift to community-based care is related to the public’s desire to participate more
actively in health care decisions, issues, and choices.
A)
Assistance with activities of daily living
B)
Immediate post-op care
C)
Mental disability services
D)
Nonmedical care for chronic illness
E)
Day care meals and
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21.
Long-term care is often needed for the elderly client. Select all the services that may be
provided to the resident in a
long-term care facility.
services Ans: A, C, D
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Feedback:
Acute/immediate post-op care is a specific need/care immediately following
surgery/procedures and is completed atthe facility. Day care meals and services are
separate services and are not provided to residents in a long-term-care facility. All the
others are part of what a long-term care facility provides.
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22.
The nurse working in the hospital understands the changes that have resulted in shorter
hospital stays, with a focus on
acute care needs of the client. Which of the following factors influence shorter hospital stays?
Select all that apply.
Federal regulations for health care reimbursement policies.
B)
Increased emphasis on preventive care.
C)
Improvement in treatment of illness.
D)
Patients realize that longer stays result in infections and other problems.
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Shorter hospital stays direct the focus on the acute care needs of the client and have
resulted from improved treatment of disease, increases in preventive care, and federal
regulations and other health care reimbursement policies. Longer hospital stays are
often the result of infection, as this factor is not related to shorter hospital stays.
23.
Medicare reimburses in-hospital costs based on a set payment for a diagnostic related
group (DRG). This means the hospital is reimbursed for a fixed amount based on the
diagnosis and projected cost for care. As a result of this system the hospital can make
a profit or a loss. Select the responses that describe when a profit for care of the
client can be
achieved.
A)
All of the hospitalization charges are less than projected.
B)
The client receives incompatible blood so the hospital does not get charged for it.
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C)
The client is discharged before the approved discharge date.
D)
The nursing care results in the client reaching outcomes for recovery, without complication,
after the projected
timetable.
Ans: A, C
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The hospital will make a profit when cost of hospitalization is less than the
reimbursement assigned for the severity of illness and projected care costs. If the
client is discharged earlier than projected the hospital keeps the total reimbursed.
Incompatible blood is a preventable error, for which the hospital is not reimbursed.
Reaching outcomes after the approved time results in additional cost to the hospital.
A)
The hospice services are provided to the families of the former residence clients only.
B)
The hospice services continue for family and friends during the bereavement period, up to one
month after the death.
C)
The hospice nurse continues to care for the client’s family for up to one year.
D)
Nurses assist the family to work through their grief during the period of mourning.
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24.
Hospice nurses provide care in a variety of settings, including clients’ homes, long-term-care
facilities, and hospice
residences. After the client dies, what happens next?
Ans: C
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After the death of the patient, the hospice nurse continues to care for the client’s
family during the bereavement period for up to one year. Nurses help the family to
work through their loss.
A)
Clients move to an independent living apartment or home, then have access to increasing
health care services as needed,
provided within the health care community where they live.
Clients move into the nursing home, and access more and more services as required in the
same facility.
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25.
One of the newest concepts in providing long-term care is called aging in place. What is the
best description of this type
of care?
D)
Clients are maintained in their own homes with home health care.
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C)
A long-term-care facility, associated with a hospital, that provides acute care services as
needed so the client can return
to long term care.
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The best description of “aging in place” is the type of care where the client moves into
an independent living space, and then has access to more services, such as assisted
living and/or skilled care, that are part of the health care community in which they live.
26.
Health care is constantly changing and becoming more complex. Select the answers that
describe clients as health care
consumers today. Select all that apply.
A)
They often have health information obtained from the Internet.
B)
They prefer to control the decisions made about their own health care.
C)
Most are less concerned about health care costs as long as they receive good care.
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D)
They express concern regarding access to care and the quality of service.
E)
They have helped develop clients’ rights and cost-containment measures.
Ans: A, B, D, E
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Health care consumers are increasingly more knowledgeable about health, and prefer
to control the decisions about their care. They express concern about access to
services, and the cost and quality of care. They question duplication of services, and
are actively engaged. They have helped to develop client rights and cost-containment
measures as protections for clients in health care settings. Today clients are surveyed
regarding their experiences with doctors and nurses in hospitals.
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The Public Health Service (PHS) is a federal agency of the U.S. Department of Health and
Human Services. The
professional nurse is aware that the services provided by the PHS include which of the
following? Select all that apply.
Care to migrant workers
B)
Care in federal prisons
C)
Veterans Administration (VA) hospitals
D)
Indian Health Services
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A)
Ans: A, B, D
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The Public Health Services provides all of these services and others, except the Veterans Administration Hospitals. VA
hospitals are supported by government-operated health care, not the PHS.
A)
Less confusion for clients regarding treatment.
B)
Increased medication errors.
C)
Clients receive more specialized care.
D)
Lack of continuity of care.
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28.
Health care costs are increasing as technology and related services increase. Patients
interact with many health care providers, such as RNs, LPNs, physicians, physical
therapists, medical technologists, radiation technologists, specialists, and others
employed in health care. As a result of the complexity of care and multiple providers,
health care is becoming
fragmented. What are the major results of fragmented care?
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Fragmented care increases health care costs and the number of providers/specialists
seeing the client. A lack of continuity of care often results, increasing the client’s
confusion, and medication errors may increase. Although clients often receive
specialized care and services, there may be conflicting care plans.
29.
A nurse is making a visit to a client in the home. As a home health care nurse you may be
expected to accomplish which
of the following?
A)
Complete an assessment on each visit.
B)
Provide support to the client and family.
C)
Administer treatments and medications.
D)
Document actions regarding patient, activities, and progress.
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The Public Health Services provides all of these services and others, except the Veterans Administration Hospitals. VA
E)
Communicate and collaborate with other members of the health team.
Ans: A, B, C, D, E
Feedback:
All of the above. Home health care nurses may provide all of these activities in the home
setting.
Nurses work with various members of the health team. The nurse understands that the
role of the hospitalist is best described as:
A)
the doctor who admits the patient, assumes the management of the patient’s care, and
maintains communication with the primary physician while the patient is hospitalized.
B)
the physician who manages the patient’s care in emergency and intensive care units only.
C)
the doctor who notifies the primary physician that their patient has been admitted to the
hospital, and transfers care to a
the referral specialist.
D)
the specialist who admits the patient to hospital, and returns care to the primary physician for
all other referrals and
services.
Ans: A
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30.
Feedback:
The hospitalist is a physician who provides care to the patient in the emergency room
and after admission to the hospital. The hospitalist communicates with the patient’s
primary doctor, but manages the hospital care.
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A nurse has been hired to work as an occupational health nurse. In this position as a registered nurse, what will this
nurse provide?
A)
Occupational therapy to schoolchildren.
B)
Education and safety programs in industrial settings.
C)
Assessment and motivation services to the unemployed.
D)
Activities to assist patients with ADLs in homeless shelters.
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Industrial settings is the best answer to define/describe occupational health nursing,
which focuses on employee safety and health-promotion programs. The other options
do not address health needs in an employment setting.
In providing nursing care, it is most important to perform which of the following actions?
A)
Administration of prescribed medications
B)
Implementation of physician’s orders
C)
Evaluation of client’s responses
D)
Coordination of care with the health care team
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32.
Ans: D
Feedback:
Nurses have moved from simply observing and giving prescribed medications to
coordinating clinical information for the entire health care team.
The U.S. system of health care is based on an ability to pay for care, which leaves
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A nurse has been hired to work as an occupational health nurse. In this position as a registered nurse, what will this
33.
millions of people uninsured or underinsured, with inadequate access to health care.
Nurses are often presented with ethical dilemmas when caring for
patients and families. Which of the following is an example of an ethical dilemma? Select all
that apply.
All clients are entitled to care, whether they can pay or not, because health care is a right.
B)
You may have to pay higher insurance premiums to cover the cost of care because you smoke.
C)
There are free clinics and health programs to serve the poor; they should receive health care
there.
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D)
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Should the uninsured person, who cannot pay for health care, receive the same care and
services as someone who works
and pays for insurance?
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Only answer D suggests an ethical dilemma for which there is no easy answer.
Answer A is an assumption that many have about health care. Answer B is a fact, as
some health insurance programs charge more for those who smoke.
Answer C is an opinion, as although there are some clinics for the poor, health care access is
limited.
34.
A nurse is caring for clients at an ambulatory care facility. Which care intervention is least
likely to be provided by the
nurse in this setting?
A)
Patient education
B)
Treatment of minor trauma
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C)
Medication administration
D)
Crisis management
Ans: D
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Nurses in ambulatory care centers and clinics provide technical services (e.g.,
administering medications), determine the priority of care needs, and provide
teaching about all aspects of care. The urgent care center is a special type of
ambulatory care center that provides walk-in care for illnesses and minor trauma.
Crisis management or intervention is typical of mental health centers and not of
ambulatory care settings.
A)
Increasing client satisfaction
B)
Controlling costs while maintaining quality of care
C)
Providing a distinct area of care
D)
Providing an all-RN staff
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35.
A nurse and a client are discussing managed care. The nurse explains that the managed care
model was designed for
which of the following reasons?
Ans: B
Feedback:
Case management is used in such situations to ensure optimum, high-quality care in
the most efficient and economic manner. It is done by controlling costs while
maintaining quality of care.
Chapter 12, Interprofessional Collaborative Practice and Care Coordination Across Settings
1.
A client asks a nurse, “How does ergotamine (Ergostat) relieve migraine headaches?” The
nurse should respond that it:
A)
dilates cerebral blood vessels.
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B)
constricts cerebral blood vessels.
C)
decreases peripheral vascular resistance.
D)
decreases the stimulation of baroreceptors.
Ans: B
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Ergotamine relieves migraine headaches by constricting, not dilating, cerebral arterial
vessels. The drug’s ability to prevent norepinephrine reuptake may add to this effect.
The net result is decreased pulsatile blood flow through the cerebral vessels and
symptom relief. Ergotamine doesn’t decrease peripheral vascular resistance or
stimulation of baroreceptors.
What role will the nurse play in transferring a client to a long-term care facility?
A)
Provide a verbal report to the nurse at the long-term care facility on the client, the hospital
care, and the client’s current
condition.
B)
Assure that the client’s original chart accompanies the client.
C)
Arrange for the client’s belongings to remain at the hospital until discharge from the long-term
care facility.
D)
Inform the client that transferring should be a stress-free situation.
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Ans: A
Feedback:
The nurse at the hospital will provide a verbal report to the nurse at the long-term
facility. The client’s belongings will accompany the client to the long-term facility,
and the nurse should assure that this occurs. The original chart will not accompany
the client, but copies of the chart or sections of the chart may be sent based upon
agency protocols. The nurse should also recognize and inform the client that while a
transfer may be a welcome event, it also can be stressful.
The nurse recognizes that the goals established for a client’s discharge are more likely to be
accomplished when …
A)
the client assists in developing the goals.
B)
the physician develops the goals.
C)
the nurse develops the goals.
D)
the multidisciplinary team develops the goals.
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3.
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Ans: A
If the client is involved in establishing the goals, it is more likely that the expected
outcomes of the discharge plan will be met. The client may fail to follow the plan if
the goals are not mutually agreed on, or are not based on a complete assessment of
the client’s needs.
4.
Which of the following phrases best describes continuity of care?
A)
Focusing on acute care in the hospital
B)
Serving the needs of children
C)
Facilitating transition between settings
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D)
Providing single-episode care services
Ans: C
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Continuity of care is a process by which health care providers give appropriate
uninterrupted care and facilitate the client’s transition between different settings and
levels of care. The other choices do not describe continuity of care.
Which of the following nursing diagnoses would be appropriate for almost all clients entering
a health care setting?
A)
Impaired Elimination
B)
Dysfunctional Grieving
C)
Fatigue
D)
Anxiety
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Entering and leaving a health care setting, as well as receiving care at home, are
experiences that produce anxiety for both clients and family members. Most clients
entering a health care setting do not have impaired elimination, dysfunctional
grieving, or fatigue.
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A)
“We will just call you Grace while you live here. Okay?”
B)
“I know you have lots of grandchildren, Grandma.”
C)
“What name do you want us to use for you?”
D)
“I think you will enjoy living here, Sweetie.”
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6.
A nurse is admitting an older woman (Grace Staples) to a long-term care facility. How should
the nurse address the
woman?
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Ans: C
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The nurse should communicate with the client as an individual so he or she can
maintain his or her own identity. Ask clients how you should address them. Do not
call older adults Grandma or Grandpa.
Which of the following is the major goal of ambulatory care facilities?
A)
To save money by not paying hospital rates
B)
To provide care to clients capable of self-care at home
C)
To perform major surgery in a community setting
D)
To perform tests prior to being admitted to the hospital
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Ans: B
Feedback:
An individual may receive care in many different kinds of ambulatory facilities,
including physician offices, clinics, hospital outpatient services, emergency rooms,
and same-day surgery centers. The goal of these facilities is to provide health care
services to patients who are able to provide self-care at home. Although this saves
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money on hospital bills, that is not the major goal of ambulatory facilities. Major
surgery and pretesting for surgery are not usually done at these centers.
A)
Physician
B)
Admission clerk
C)
Licensed practical nurse
D)
Registered nurse
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8.
According to established standards, which health care provider should conduct a holistic
assessment for all clients
admitted to the hospital?
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The Joint Commission has established standards for hospital admission. These
standards include assessment of each client’s need for nursing care by a registered
nurse and biophysical, psychosocial, environmental, self-care, educational, and
discharge planning factors. The admission health assessment is not the responsibility
of the physician, licensed practical nurse, or admission clerk.
9.
Which health care provider is responsible for ensuring the room is prepared for admission and
that the client is
welcomed?
A)
Nursing assistant
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B)
Admitting room clerk
C)
Social worker
D)
Nurse
Ans: D
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Although the nurse may delegate most of the activities necessary to prepare a room
for an admission, it is the nurse’s responsibility to ensure other personnel complete
the activities and to welcome the client to the unit.
A)
By giving a verbal report to nurses in the ICU
B)
By ensuring that the chart and all belongings are moved
C)
By delegating a nursing assistant to provide information
D)
By asking the family to provide the information
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10.
A client has suddenly become very ill, and a nurse is transferring him to the intensive care unit
(ICU). How does the
nurse provide information to ensure continuity of care?
Ans: A
Feedback:
When a client is transferred to another unit, the nurse in the original unit gives a
verbal report about the client to the nurse in the new area. Continuity of care is not
ensured by moving the chart and belongings, delegating responsibility to a nursing
assistant, or asking the family to provide information.
11.
At what point during hospital-based care does planning for discharge begin?
A)
Upon admission to the hospital
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B)
After the patient is settled in a room
C)
Immediately before discharge
D)
After leaving the hospital
Ans: A
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Planning for discharge begins on admission to the hospital, when admission
information about the client is collected and documented.
A)
Tell the wife exactly how to do it.
B)
Give the wife information about supplies.
C)
Have the wife demonstrate the procedure.
D)
Ask another nurse to reinforce teaching.
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12.
A nurse, preparing for a client’s discharge after surgery, is teaching the client’s wife to change
the dressing. How can the
nurse be certain the wife knows the procedure?
Ans: C
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All steps of a procedure should be demonstrated, practiced, and provided in writing.
The client or caregiver should then perform the procedure in the presence of the nurse
to demonstrate understanding. Simply stating the information, providing information
about supplies, or asking another nurse to reinforce teaching does not mean the
caregiver knows the information.
What is required of a client who leaves the hospital against medical advice (AMA)?
A)
Nothing. The hospital has no legal concerns.
B)
Full reimbursement of any medical expenses
C)
Providing contact phone numbers if needed
D)
Signing a form releasing legal responsibility
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A client is legally free to leave the hospital, but must sign a form that releases the
physician and health care institution from any legal responsibility for his or her health
status. The client’s signature must be witnessed, and the form becomes part of the
client’s medical record.
14.
A home health care agency providing care in a local community is supported by the United
Way and local donations.
What type of agency is this?
A)
Voluntary
B)
Public
C)
Proprietary
D)
Institution-based
Ans: A
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Feedback:
Home care agencies differ in the way they are organized and administered. They may
be official or public (operated by state or local governments and primarily financed
by tax funds), voluntary or not-for-profit (supported by donations, endowments,
charities, and insurance reimbursements), proprietary (for-profit organizations
governed by individual owners or national corporations), or institution-based (operate
under a parent organization, such as a hospital).
Why would a home health care agency choose to be certified by Medicare?
A)
To remain open and offer services
B)
To ensure that all available services can be provided
C)
To receive reimbursement for Medicare-covered services
D)
To be able to admit clients without a physician’s order
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There are two types of home health care agencies: those certified by Medicare and
those that are not. An agency must be certified by Medicare in order to receive
reimbursement for Medicare-covered services.
16.
In addition to a physician’s order, what is one of the eligibility requirements for Medicarecovered home health care?
A)
The client must have transportation to the physician’s office.
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B)
The family must be willing to meet health care needs.
C)
The client must be essentially homebound.
D)
The client must be able to leave the home unassisted.
Ans: C
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To be eligible for Medicare-covered home health care services, the client must meet
certain criteria. One is that the client must be homebound or normally unable to
leave the home unassisted. The client may leave home for medical treatment or
short, infrequent trips, but leaving the home must require considerable effort.
What is the goal of nurses who provide home health care?
A)
Helping clients achieve maximum independence and health
B)
Collaborating with other health care providers and services
C)
Minimizing the manifestations of disease processes
D)
Encouraging clients’ dependence on family members
Ans: A
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17.
Feedback:
The essential components of home health care include the client, the family, and
health care professionals from various disciplines. The goal of nursing care in the
home is to help clients reach maximum independence and health. Although nurses
collaborate with other health care providers, they do so to meet this goal. Home
health care is not provided to minimize disease manifestations or to encourage
clients’ dependence on family members.
18.
Which of the following health care professionals prescribes home care and certifies the plan of
care for the client?
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A)
Social worker
B)
Discharge nurse
C)
Home healthcare nurse
D)
Physician
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The physician certifies the client has a health problem so that the client may receive
home health care services. The physician also prescribes and certifies a plan of care
for the client. The plan is not certified by a social worker, discharge nurse, or home
health care nurse.
A)
Computer knowledge, cultural diversity
B)
Physical assessment, infection control
C)
Communications, technical skills
D)
Documentation,
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19.
Although all of the following components are important, which two components of nursing
care are identified by home
health care nurses as most important when caring for clients in the home?
problem solving Ans: B
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Feedback:
Home health care nurses have identified the following areas of knowledge as most
important: legal regulations, physical assessment, body mechanics, nursing
diagnoses, and infection control.
A)
Direct care provider
B)
Coordinator of services
C)
Educator
D)
Advocate
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20.
A client is having problems with insurance reimbursement. The home health care nurse
discusses the client’s need for
home health services with the insurance company. What role is the nurse demonstrating?
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Patients often need help understanding the complex health care system, including
handling insurance problems. Advocacy (the protection and support of another’s
rights) is an important role of the home health care nurse. By convincing the
insurance company of the client’s continued need for home care services, the nurse is
acting as an advocate.
21.
Which one of the following roles of the home health care nurse illustrates the role of
coordinator of services?
A)
Providing certification for home care
B)
Providing direct physical care to the client
C)
Providing information about community resources
D)
Educating the client and caregiver about wound care
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Ans: C
Feedback:
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The home health care nurse is generally the coordinator of all other health care
providers visiting the client. He or she is also responsible for coordinating community
resources needed by the client. The nurse does not provide certification. Providing
direct care is a part of the caregiver role, whereas educating about wound care is part
of the educator role.
Which of the following is recommended to ensure safety for the home health care nurse?
A)
Traveling with another nurse
B)
Carrying a cell phone
C)
Talking to family members
D)
Refusing assignments
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22.
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Ans: B
The nurse must evaluate the safety of the neighborhood before making the first home
visit. Guidelines for safety of the nurse include carrying a cell phone programmed
with emergency numbers. In most instances, it is not economically feasible to travel
with another nurse. Talking to family members and refusing assignments do not
ensure safety.
23.
What must a nurse do before altering the arrangement of furniture in the home to facilitate
care?
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A)
Nothing; the nurse may move the furniture if needed.
B)
Document the need to move the furniture.
C)
Tell the client that the furniture has to be moved.
D)
Ask the client’s permission to move the furniture.
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The nurse may believe the furniture in the client’s home needs to be rearranged to
allow the use of equipment and to remove safety hazards, but the client should give
permission before any changes are made. It is not necessary to document the need to
move furniture.
What technique should the nurse use to implement infection control in the home?
A)
Avoid touching any object in the home, including door knobs.
B)
Practice hand hygiene when beginning and ending the home visit.
C)
Wear gloves at all times when in the home or traveling in the car.
D)
Take prescribed antibiotics on a regular basis on working days.
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Ans: B
Feedback:
Of all the methods used to prevent infection, hand hygiene is the most important and
is necessary before and after treating the client (i.e., when beginning and ending the
home visit).
25.
A client is diagnosed with mild dementia while in the hospital. In preparing for discharge,
what should the nurse should
discuss with the family?
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A)
Possible need for home care
B)
Legal responsibility for the future
C)
Need for transfer to a long-term care facility
D)
Lack of free resources of care
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The needs of the client should be considered when making discharge plans. Common
risk factors associated with the need for home care include limited social, mental, or
physical functioning. Legal issues, long-term care, and free resources are not
indicated in this situation.
A)
Developing rapport
B)
Making assessments
C)
Evaluating safety issues
D)
Gathering supplies
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26.
Which of the following are examples of nursing actions performed in the entry phase of the
home visit? Select all that
apply.
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E)
Collecting client information
Ans: A, B
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In the entry phase, the nurse develops rapport with the patient and family, makes
assessments, determines nursing diagnoses, establishes desired outcomes (along with
the client and family), plans and implements prescribed care, and provides education.
In the pre-entry phase, the nurse evaluates safety issues, gathers supplies, and collects
client information.
A)
Evaluate the client’s functional level.
B)
Provide muscle-strengthening exercises.
C)
Educate client and family about promoting self-care in ADLs.
D)
Provide assistance with securing needed equipment.
E)
Implement the plan of care designed by the nurse.
Ans: A, C
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27.
Which of the following interventions would be performed by the occupational therapist as a
member of the home health
care team? Select all that apply.
Feedback:
The occupational therapist evaluates the client’s functional level, educates the client
and family on promoting self-care in activities of daily living, assesses the home for
safety, and provides adaptive equipment (as necessary). Muscle- strengthening
exercises are provided by the physical therapist. Assistance with securing needed
equipment is provided by the social worker. The home health aide implements the
plan of care designed by the nurse, and the nurse researches the cost-effectiveness of
the plan.
Which of the following roles of the nurse is most important in providing continuity of care to
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clients? Select all that
apply.
A)
Educator
B)
Collaborator
C)
Mentor
D)
Advocate
E)
Role model
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Ans: A, B, D
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To provide continuity of care, nurses must consider education and referrals in the
care of any person admitted to any type of health care setting, and must also involve
the client and family in a mutual planning process. The nurse must also collaborate
with other members of the health care team in meeting the physical, psychological,
sociocultural, and spiritual needs of the client and family, in all settings and at all
levels of health or illness. Although it is important to be a mentor, role model, and
researcher, these roles are not directly related to providing continuity of care.
29.
The nurse is planning the discharge of a client who had surgery for a left hip
replacement. The client is being discharged from the hospital to the home and
requires a walker and high-rise toilet seat. Which type of home health care service
does the client require?
A)
Custodial services
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B)
Home medical services
C)
High-technology pharmacology services
D)
Hospice services
Ans: B
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Home medical services provide durable medical equipment, such as walkers, canes,
crutches, wheelchairs, high-rise toilet seats, commodes, beds, and oxygen. Custodial
services include homemaking and housekeeping services, as well as companionship
and live-in services. Hospice services provide pain management, physician services,
spiritual support, respite care, and bereavement counseling. High-technology
pharmacology services provide intravenous therapy, home uterine monitoring,
ventilator management, and chemotherapy.
A)
Tell me what responsibilities each member of the family has.
B)
“Can we get rid of some of this clutter in your home?
C)
What do you believe is causing your illness?
D)
What foods are important in your family life?
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30.
The nurse is identifying needs of the client and family during the initial home visit. Which
question would be
inappropriate for the nurse to ask?
Ans: B
Feedback:
When identifying needs of the client and family the nurse needs to consider the
culture of the family unit. Information regarding the responsibilities of each family
member, cultural foods important to the family, and the family members’ perceptions
of what is causing the illness can assist the nurse in providing culturally sensitive
care. The nurse also needs to assess the physical environment of the home. However,
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referring to the home as cluttered is a judgmental statement that will cause the family
to become defensive and will prevent the development of a trusting relationship.
31.
The Joint Commission is one agency that accredits health care institutions. The nurse
understands that the Joint
Commission has mandated the use of which national safety practice to protect clients admitted
to a health care facility?
Nurses use the Rights checklist prior to administering medications.
B)
Upon admission all clients sign advanced directives.
C)
The use of a wristband for identification of the patient.
D)
The use of standard precautions in the operating room.
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The Joint Commission accredits health care organizations and has required that to
maintain client safety the wristband with the identification number/bar-code, client’s
name, physician’s name, and other important identifying information be worn by the
client. It does not require clients to sign advanced directives, and does not regulate
nursing practice regarding medications and standard precautions.
32.
Nursing continues to recognize and participate in providing appropriate, uninterrupted care
and facilitate clients’
transitions between different settings and levels of care. What would be an example of this
continuity of care?
A)
The nurse collaborating with other members of the health care team
B)
The nurse accompanying the physician on rounds
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C)
The nurse taking detailed notes on how each client wants to continue care
D)
The nurse attending an appointment with the client in some place other than where the nurse
works
Ans: A
Feedback:
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Continuity of care is a process by which health care providers give appropriate,
uninterrupted care and facilitate a client’s transition between different settings and
levels of care. To do this, the nurse must, along with other responsibilities,
collaborate with other members of the health care team in meeting all the needs of
each client. The other answers are incorrect because they are not examples of the idea
of the continuity of care.
A)
Money focused
B)
Client focused
C)
Primary nursing
D)
Functional nursing
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33.
The models of nursing care delivery have been many and varied throughout the history of
nursing. Which of the
following best describes the idea of the continuity of care?
Ans: B
Feedback:
Community-based nursing practice, admission and discharge from a health care
setting, transfer from one setting to another, and readiness for home health care all
have to do with the continuity of care and are client-focused. In other words, they
focus on a client’s needs and the nurse’s role in providing that continuity. The other
answers are incorrect.
The wristband is an important safety component during the client’s stay because it is
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A)
The Joint Commission
B)
NANDA
C)
HIPAA
D)
The Kardex
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34.
one of two identifiers required by which group’s national safety standards (2008) to
accurately identify a client during such activities as giving medication,
fluids, and blood?
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The wristband is an important safety component during the client’s stay because it is
one of two identifiers required by The Joint Commission’s national safety standards
(2008) to accurately identify a patient during such activities as giving medication,
fluids, and blood.
A)
Identify community services initially for the client
B)
Obtain client information from the discharge planner
C)
Call the client to obtain permission to visit
D)
Schedule a home health aide to visit the client
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35.
The home health nurse receives a referral from the hospital for a client who needs a home
visit. After reading the
referral, what would be the first action the nurse should take?
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Ans: B
Feedback:
After receiving a referral, the first step is to call the physician or discharge planner to
collect as much information as possible about the client. After the nurse reviews the
information, he or she can call the client to obtain permission and schedule the visit.
The nurse may identify community services or the need for a home health aide after
she assesses the client and the home environment during the first visit with the client.
Chapter 13, Blended Competencies Clinical Reasoning, and Processes of Person-Centered Care
A)
Cognitive skill
B)
Technical skill
C)
Interpersonal skill
D)
Ethical/legal skill
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1.
The nursing student uses evidence-based practice findings in the development of a care plan.
This is an example of
which type of nursing skill?
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Ans: A
Feedback:
The student is demonstrating the use of cognitive skills, which is characterized by
identifying scientific rationales for the client’s plan of care, selecting nursing
interventions that are most likely to yield the desired outcomes, and using critical
thinking to solve problems. Technical skills focus on manipulating equipment
skillfully to produce a desired outcome. Interpersonal skills are used to establish and
maintain a caring relationship. Ethically and legally skilled nurses conduct
themselves in a manner consistent with their personal moral code and professional
role responsibilities.
A nurse has come on day shift and is assessing the client’s intravenous setup. The
nurse notes that there is a mini-bag of the client’s antibiotic hanging as a piggyback,
but that the bag is still full. The nurse examines the patient’s medication
administration record (MAR) and concludes that the night nurse likely hung the
antibiotic but failed to start the infusion. As a result, the antibiotic is three hours late
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and the nurse has consequently filled out an incident report. In doing so, the
nurse has exhibited which of the following?
A)
Ethical/legal skills
B)
Technical skills
C)
Interpersonal skills
D)
Cognitive skills
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Reporting problems and unacceptable practices is an aspect of ethical/legal skills.
Technical skills enable the safe performance of kinesthetic tasks while interpersonal
skills are the manifestations of caring. Cognitive skills encompass knowledge and
critical thinking.
A)
Starting a new, large-gauge intravenous site on the client, and priming the infusion tubing
B)
Understanding the Rh system that underlies the client’s blood type
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3.
A client who has been admitted to the hospital for the treatment of a gastrointestinal
bleed requires a transfusion of packed red blood cells. Which of the following aspects
of the nurse’s execution of this order demonstrates technical
skill?
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C)
Ensuring that informed consent has been obtained and properly filed in the client’s chart
D)
Explaining the process that will be involved in preparing and administering the transfusion
Ans: A
Feedback:
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Performing tasks that require manual dexterity is a manifestation of technical skills.
Explaining the transfusion process is largely dependent on interpersonal skills,
while understanding the theory behind blood types is indicative of cognitive skills.
Informed consent lies within the domain of legal/ethical skills.
In which of the following situations would the nurse be most justified in implementing trialand-error problem solving?
A)
The nurse is attempting to landmark an obese client’s apical pulse.
B)
The nurse is attempting to determine the range of motion of a client’s hip joint following hip
surgery.
C)
The nurse is attempting to determine which PRN (as needed) analgesic to offer a client who is
in pain.
D)
The nurse is attempting to determine whether a poststroke client has a swallowing deficit.
Ans: A
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4.
Feedback:
Trial-and-error problem solving can be dangerous to the client. Testing range of
motion by trial-and-error could result in dislocation; trial-and-error drug
administration could result in over- or under-medicating; trial-and-error assessment
of a potential swallowing deficit could result in aspiration. Each of these situations
warrants more systematic problem solving. Trial-and-error landmarking of an
anatomically difficult point, such as the apex of an obese client’s heart, does not pose
a threat to the client and a reasonable amount of “hunting” for the apical pulse may
be necessary.
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5.
What nursing organization first legitimized the use of the nursing process?
A)
National League for Nursing
B)
American Nurses Association
C)
International Council of Nursing
D)
State Board of Nursing
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Ans: B
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Although the term “nursing process” was first used by Lydia Hall in 1955 and
nursing theorists delineated specific steps in a process approach to nursing, use of the
nursing process was legitimized in 1973, when the American Nurses Association’s
Congress for Nursing Practice developed Standards of Practice to guide nursing
performance.
A)
Assessing
B)
Diagnosing
C)
Planning
D)
Implemen
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6.
A client comes to the emergency department complaining of severe chest pain. The nurse asks
the client questions and
takes vital signs. Which step of the nursing process is the nurse demonstrating?
ting Ans: A
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Feedback:
Assessing is the step in which nurses assess the client to determine the need for
nursing care. When assessing, the nurse systematically collects client data.
B)
Diagnosing
C)
Planning
D)
Implementing
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7.
A nurse is examining a child two years of age. Based on her findings, she initiates a care plan
for a potential problem
with normal growth and development. Which step of the nursing process identifies actual and
potential problems?
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After assessing the need for nursing care, the nurse clearly identifies client strengths,
and actual and potential problems in diagnoses.
8.
A home health nurse reviews the nursing care with the client and family and then mutually
discusses the expected
outcomes of the nursing care to be provided. Which step of the nursing process is the nurse
illustrating?
A)
Diagnosing
B)
Planning
C)
Implementing
D)
Evaluating
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Ans: B
Feedback:
During the planning step, the nurse identifies expected outcomes of the plan of care.
The plan of care should beholistic and individualized, specify desired client goals and
related outcomes, and identify the nursing interventions most likely to meet those
expected outcomes.
A)
Assessing
B)
Planning
C)
Implementing
D)
Evaluating
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9.
Based on an established plan of care, a nurse turns a client every two hours. What part of the
nursing process is the nurse
using?
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During the implementing step of the nursing process, the nurse carries out
interventions that were developed during the planning step.
10.
What name is given to standardized plans of care?
A)
Critical pathways
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B)
Computer databases
C)
Nursing problems
D)
Care plan templates
Ans: A
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Standardized care plans include critical pathways, which target desired outcomes for
particular illnesses, procedures, or conditions along a timeline. Critical pathways are
used in many health care settings.
A)
NANDA
B)
NIC
C)
NOC
D)
HHCC (now CCC)
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11.
Which of the following groups developed standard language to increase the visibility of
nursing’s contribution to client
care by continuing to develop, refine, and classify phenomena of concern to nurses?
Ans: A
Feedback:
The North American Nursing Diagnosis Association (NANDA) International
increased the visibility of nursing’s contribution to client care by continuing to
develop, refine, and classify phenomena of concern to nurses. The Nursing
Interventions Classification (NIC) works to identify, label, validate, and classify
actions nurses perform, including direct and indirect care interventions. The NursingSensitive Outcomes Classification (NOC) identifies, validates, and classifies
nursing-sensitive client outcomes and indicators to evaluate the validity and
usefulness of the classification.
Home Health Care Classification (HHCC, now known as Clinical Care
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Classification (CCC) system) provides a structure for documenting and classifying
home health and ambulatory care.
Legally speaking, how would the nurse ensure that care was not negligent?
A)
Verbally reporting assessments to the client’s physician
B)
Keeping private notes about the care given to each assigned client
C)
Documenting the nursing actions in the client’s record
D)
Tape recording complete information for each oncoming shift
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Legally speaking, a nursing action not documented in the client’s record is a nursing
action not performed. Unless the record contains written (not verbal, tape-recorded,
or in private notes) documentation of care provided, the court would have no reason
to accept a nurse’s claim that the care was given.
A)
Systematic
B)
Dynamic
C)
Outcome oriented
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13.
A nurse interviews a pregnant teenager and documents her answers on the client
record. At the same time, the nurse responds to the client’s concerns and makes a
referral for counseling and maternity care. This scenario is an example of
which of the descriptors of the nursing process?
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D)
Universally applicable
Ans: B
Feedback:
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Although the nursing process is presented as an orderly progression of steps, in
reality there is great interaction and overlapping among the five steps. No one step in
the nursing process is a one-time phenomenon; each step flows into the next step. In
some nursing situations, all five stages occur almost simultaneously.
A)
Trial-and-error problem solving
B)
Intuitive thinking
C)
Scientific problem solving
D)
Methodical reasoning
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14.
An experienced ICU nurse is mentoring a student. The nurse tells the student, “I think
something is going wrong with
your client.” What type of clinical decision making is the experienced nurse demonstrating?
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Ans: B
Feedback:
Nurses today acknowledge the role of intuitive thinking in clinical decision making.
Many veteran nurses can describe situations in which an “inner prompting” led to a
quick nursing intervention that saved a client’s life. However, intuitive problem
solving comes with years of practice and observation.
15.
A nurse is caring for a client in the ER who was injured in a snowmobile accident.
The nurse documents the following client data: uncontrollable shivering, weakness,
pale and cold skin. Th nurse suspects the client is experiencing hypothermia. Upon
further assessment, the nurse notes a heart rate of 53 BPM and core internal
temperature of 90°F, which confirms the initial diagnosis. The nurse then devises a
plan of care and continues to monitor the client to evaluate
the outcomes. This nurse is using which of the following types of problem solving in her care
of this client?
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A)
Trial-and-error
B)
Scientific
C)
Intuitive
D)
Critical thinking
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Scientific problem solving is a systematic, seven-step, problem-solving process that involves
(1) problemidentification,
(2) data collection, (3) hypothesis formulation, (4) plan of action, (5) hypothesis testing, (6)
interpretation of results,and
(7) evaluation, resulting in conclusion or revision of the study. This method is used
most correctly in a controlled laboratory setting but is closely related to the more
general problem-solving processes commonly used by health care professionals as
they work with clients, such as the nursing process.
Which of the following is one example of a client benefit of using the nursing process?
A)
Greater personal satisfaction
B)
Decreased reliance on the nursing staff
C)
Continuity of care
D)
Decreased incidence of medical errors
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Ans: C
Feedback:
When used well, the nursing process achieves for the client scientifically based,
holistic, individualized care; the opportunity to work collaboratively with nurses;
and continuity of care.
What is a systematic way to form and shape one’s thinking?
A)
Critical thinking
B)
Intuitive thinking
C)
Trial-and-error
D)
Interpersonal values
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Critical thinking is defined as “a systematic way to form and shape one’s thinking.
It functions purposefully and exactingly. It is thought that is disciplined,
comprehensive, based on intellectual standards, and, as a result, well- reasoned”
(Paul, 1993, p. 20).
18.
What step in the nursing process is most closely associated with cognitively skilled nurses?
A)
Assessing
B)
Planning
C)
Implementing
D)
Evaluating
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Ans: B
Feedback:
Cognitively skilled nurses are critical thinkers and are able to select those nursing
interventions that are most likely to yield the desired outcomes.
Cognitive skills
B)
Interpersonal skills
C)
Technical skills
D)
Ethical/legal skills
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19.
A nurse asks a multidisciplinary team to collaborate in developing the most appropriate plan
of care to meet the needs of
an adolescent with a severe head injury. Which of the blended skills essential to nursing
practice is the nurse using?
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Interpersonally skilled nurses establish and maintain caring relationships that
facilitate the achievement of valued goals, and simultaneously affirm the worth of
those in the relationship. They are, among other things, able to work collaboratively
with the health care team to reach valued goals.
20.
A student is asked to perform a skill for which he is not prepared. When using the method of
critical thinking, what
would be the first step to resolve the situation?
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A)
Purpose of thinking
B)
Adequacy of knowledge
C)
Potential problems
D)
Helpful resources
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The student’s first step when thinking critically about a situation is to identify the
purpose or goal of the thinking. This helps to discipline thinking by directing all
thoughts toward the goal.
A)
Being curious and persevering
B)
Being creative
C)
Demonstrating confidence
D)
Thinking independently
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21.
Members of the staff on a hospital unit are critical of a client’s family, who has
different cultural beliefs about health and illness. A student assigned to the patient
does not agree,based on her care of the client and family. What critical thinking
attitude is the student demonstrating?
Ans: D
Feedback:
Although all the attitudes listed are components of critical thinking, the student is
thinking independently. Nurses who are independent thinkers are careful not to let
the status quo or a persuasive individual control their thinking.
22.
As a beginning student in nursing, what is essential to the mastery of technical skills, such as
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giving an injection?
A)
Read the steps of the procedure before clinical assignments.
B)
Even if you do not know how to give an injection, act as if you do.
C)
Practice giving injections in the learning laboratory until you feel comfortable.
D)
Tell your instructor that you don’t think you can ever give an injection.
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Before attempting to perform a technical skill with or on a patient, it is necessary for
the nurse to practice that skill until he or she feels confident in doing it.
Which of the following interpersonal skills is essential to the practice of nursing?
A)
Performing technical skills knowledgeably and safely
B)
Maintaining emotional distance from clients and families
C)
Keeping personal information among shared clients confidential
D)
Promoting the dignity and respect of
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23.
patients as people Ans: D
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Feedback:
Characteristics of interpersonal caring that are essential to the practice of nursing
include promoting the dignity and respect of clients as people, the centrality of the
caring relationship, and a mutual enrichment of both participants in the nurse–client
relationship.
A)
The nurse cleans the wound and applies a dressing to it.
B)
The nurse inspects and examines the wound for swelling.
C)
The nurse tells the client to use caution while on slippery surfaces.
D)
The nurse informs the client that the wound is small and will heal easily.
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24.
A client age 50 years reports to a primary care unit with an open wound due to a fall in the
bathroom. Which of the
following nursing actions represents caring skills?
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The nursing action of cleaning the wound and applying a dressing indicates caring
skills. The nurse implements assessment skills while inspecting and examining the
wound. The nurse counsels the client to use caution when walking on slippery
surfaces. By informing the client about the wound’s condition, the nurse uses
comforting skills.
25.
The nurse, after gathering data, analyzes the information to derive meaning. The nurse is
involved in which phase of the
nursing process?
A)
Planning
B)
Diagnosis
C)
Implementation
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D)
Outcome identification
Ans: B
Feedback:
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The diagnosis phase involves the analysis of information and deriving the meaning
from the analysis. The planning phase involves preparing a care plan and directing
the nursing staff in providing care. The implementation phase involves initiation,
evaluation of response to the plan, record of nursing actions, and client response to
actions. Outcome identification involves formulating and documenting measurable,
realistic, client-focused goals.
A)
Severe bleeding from a wound
B)
History of asthma
C)
Diabetes
D)
Lack of family support
Ans: A
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26.
After completing an assessment of a client, the nurse uses critical thinking and clinical
reasoning to prioritize the client’s
problems. Which of the following would the nurse determine is the highest priority?
Feedback:
The client’s problem is considered to be of high priority if it is life threatening,
requires more intervention time, and has serious consequences. The severe bleeding
from a wound would be the highest priority. The client’s history of asthma, diabetes,
and lack of family support may be important but the bleeding is the priority.
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A)
Assessment
B)
Planning
C)
Implementation
D)
Evaluation
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27.
When the nurse is administering Lasix 20 mg to a client in congestive heart failure, what phase
of the nursing process
does this represent?
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Implementation refers to the action phase of the nursing process, in which nursing care is
provided.
When the nurse assesses the client’s blood sugar, what is the term for the type of skill the
nurse is using?
A)
Technical
B)
Therapeutic
C)
Interactional
D)
Adaptive
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28.
Ans: A
Feedback:
Technical skills are used to carry out treatments and procedures.
Nurses apply critical thinking to clinical reasoning and judgment in their nursing practice
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A)
It is guided by standards, policies and procedures, ethics codes, and laws.
B)
It is based on principles of nursing process, problem solving, and the scientific method.
C)
It carefully identifies the key problems, issues, and risks involved.
D)
It is driven by the nurse’s need to document competent, efficient care.
E)
It calls for strategies that make the most of human potential.
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29.
every day. Which of the
following are characteristics of this practice? Select all that apply.
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Critical thinking is guided by standards, policies and procedures, ethics codes, and
laws; is based on principles of nursing process, problem solving, and the scientific
method; and carefully identifies the key problems, issues, and risks involved. It is
driven by client, family, and community needs, as well as nurses’ needs to give
competent, efficient care (e.g., streamlining paperwork to free nurses for client care).
It calls for strategies that make the most of human potential and compensate for
problems created by human nature. It is constantly re-evaluating, self-correcting, and
striving to improve.
30.
Nurses make decisions in their practice every day. Which of the following are potential errors
in this decision-making
process? Select all that apply.
A)
Placing emphasis on the last data received
B)
Avoiding information contrary to one’s opinion
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C)
Selecting alternatives to maintain status quo
D)
Being predisposed to multiple solutions
E)
Prioritizing problems in order of importance
Ans: B, C
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Potential errors in decision making include bias: placing emphasis on the first data
received, avoiding information contrary to one’s opinion, selecting alternatives to
maintain status quo, and being predisposed to a single solution. Failure to prioritize
problems in order of importance is failure to consider the total situation. Failure to
use appropriate resources is impatience. All these actions can lead to errors in
decision making (Lipe & Beasley, 2004.)
Which of the following is an essential feature of professional nursing? Select all that apply.
A)
Providing a caring relationship to facilitate health and healing
B)
Attention to a range of human experiences and responses to health and illness
C)
Use of objective data to negate the client’s subjective experience
D)
Use of judgment and critical thinking to form a medical diagnosis
E)
Advancement of professional nursing knowledge through scholarly inquiry
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31.
Ans: A, B, E
Feedback:
As the role has changed, definitions of nursing have evolved to acknowledge the
following essential features of professional nursing: (1) providing a caring
relationship that facilitates health and healing, (2) attention to the range of human
experiences and responses to health and illness within the physical and social
environments, (3) integration of objective data with knowledge gained from an
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appreciation of the client’s or group’s subjective experience, (4) application of
scientific knowledge to the processes of diagnosis and treatment through the use of
judgment and critical thinking, (5) advancement of professional nursing knowledge
through scholarly inquiry, and (6) influence on social and public policy to promote
social justice.
A)
Promoting the nurse’s self-esteem.
B)
Reflective practice.
C)
Assessment of oneself.
D)
Learning from mistakes.
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32.
Self-evaluation is a method that nurses use to promote their own development, and to grow in
confidence in their
nursing roles. This process is referred to as what?
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Reflective practice is the use of self-evaluation by nurses committed to quality
nursing practice. The others may be additional gains but are not descriptive of selfevaluation.
33.
Nursing is a profession in a rapidly changing health care environment. What is the most
important reason for the nurse
to develop critical thinking and clinical reasoning?
A)
To be able to employ the nursing process in client care.
B)
The licensing examination requires nurses to be adept at critical thinking.
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C)
Because clients deserve experts who know how to care for them.
D) To provide quality care with nursing ability and knowledge.
Ans: D
Feedback:
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The goal of all nursing is to meet the standard of quality care. Clinical reasoning and
critical thinking may be applied in all of the answers but the most important goal in
health care is to provide quality nursing care to clients.
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34.
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The nurse is providing care for a pediatric client on night shift. At 0400, the nurse
notes that the child has a high fever but does not have an order for an antipyretic.
What nursing action represents a good example of teamwork and
collaboration as defined by the Quality and Safety Education for Nurses (QSEN)
competencies? The nurse:
calls the health care practitioner, reports her findings, and requests an order for an antipyretic.
B)
gives the child a common over-the-counter antipyretic based on dosing recommendations and
reports this to the
oncoming nurse.
C)
reports to the oncoming nurse at 0700 that the child has a fever so that when the healthcare
provider comes in, she can
obtain an order for an antipyretic.
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A)
requests that the child ‘s mother give the child something for the fever that she brought from
home.
Ans: A
Feedback:
Teamwork and collaboration as defined by QSEN indicates the need to recognize
practice boundaries at the same time as functioning within the inter-professional
team to accomplish shared decision making. It is the nurses responsibility to report
altered client status that may require collaborative interventions, irregardless of time
of day. For the nurse to administer a medication, there must be a written order for the
medication, and it is outside of the scope of practice to prescribe medications.
Waiting to report the assessment to an oncoming nurse may delay client care and
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C)
Because clients deserve experts who know how to care for them.
effect client outcomes. It would be inappropriate to require the mother take care of
this with medications brought from home.
Which of the following group of terms best describes the nursing process?
A)
nursing goals, medical terminology, linear
B)
nurse-centered, single focus, blended skills
C)
patient-centered, systematic, outcomes-oriented
D)
family-centered, single point in time, intuitive
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Ans: C
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The nursing process is a patient-centered, systematic, outcomes-oriented method of
caring that provides a framework for nursing practice. It is nursing practice in action.
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Chapter 14, Clinical Judgement & Chapter 15, Assessing
A)
“Assessment data about the client should be collected continuously.”
B)
“Assess your client after receiving the nursing report and again before giving a report to the
next shift of nurses.”
C)
“Assess your client at least hourly if the client’s vital signs are unstable, and
every two hours if the vital signs are stable.”
D)
“Assessment data should be collected prior to the physician rounding on the unit.”
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1.
Which of the following guidelines should a nursing instructor provide to nursing students who
are now responsible for
assessing their clients?
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Data about the client are collected continuously because the client’s health status can change
quickly.
2.
The nurse is using a systematic approach to the collection of assessment data. The
nurse uses an assessment guide that uses a hierarchy of five life requirements
universal to all persons. What model for organizing the assessment data is the
nurse using?
A)
Human Needs (Maslow) model
B)
Functional Health Patterns model
C)
Human Response Patterns model
D)
Body System model
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Ans: A
Feedback:
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The nurse is following the Human Needs model based on Maslow’s Hierarchy of
Human Needs. The Functional Health Patterns model was developed by Gordon and
is a framework that identifies 11 functional health patterns and organizes data
according to these patterns. The Body System model is often used by the medical
community, and it organizes data according to organ and tissue function in various
body systems. The Human Response Pattern model focuses on a unitary person.
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A)
Encourage the novice nurse to independently observe the same situation with a peer, validate
the data, and discuss the
situation afterward.
B)
Encourage the novice nurse to develop his or her own tool for data collection.
C)
Encourage the novice nurse to collect and interpret the data for the client repeatedly, until the
novice nurse arrives at the
correct interpretation.
D)
Encourage the novice nurse to meet with the nurse manager to discuss the situation and seek
mentoring for
communication skills.
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3.
A novice nurse collects data on a newly admitted client. Upon evaluation of this data, the
nurse provides an erroneous
interpretation. What is a corrective action for this interpretation?
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Ans: A
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The novice nurse can improve interpretation skills by independently observing the
same situation with a peer, comparing notes afterward, and role-playing various
validation techniques.
4.
When documenting subjective data, the nurse should do which of the following?
A)
Use the client’s own words placed in quotation marks.
B)
Paraphrase the information stated by the client.
C)
Validate the information with the client’s family prior to documentation.
D)
Record the information using nonspecific words.
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Ans: A
Feedback:
Subjective data should be recorded using the client’s own words, whenever possible.
Quotation marks should be used around the client’s statement. The tendency to use
nonspecific terms that are subject to individual definition or interpretation should be
avoided.
A)
Measure the client’s oral temperature.
B)
Ask a colleague for assistance.
C)
Give the client a clean gown and warm blankets.
D)
Obtain an order for blood cultures.
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5.
The nurse has entered a client’s room to find the client diaphoretic (sweat-covered) and
shivering, inferring that the
client has a fever. How should the nurse best follow up this cue and inference?
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Ans: A
An inference must be followed by a validation process. In this case, the inference of
fever is best validated or rejected by measuring the client’s temperature. This should
precede interventions such as blood work or even providing a warm blanket.
6.
The nurse completes a health history and physical assessment on a client who has been
admitted to the hospital for
surgery. What is the purpose of this initial assessment?
A)
To gather data about a specific and current health problem
B)
To identify life-threatening problems that require immediate attention
C)
To compare and contrast current health status to baseline data
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D)
To establish a database to identify problems and strengths
Ans: D
Feedback:
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An initial assessment is performed shortly after the client is admitted to a health care
agency or service. The purpose of the initial assessment is to establish a complete
database for problem identification and care planning.
A)
Initial assessment
B)
Focused assessment
C)
Emergency assessment
D)
Time-lapsed assessment
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7.
A client comes to her health care provider’s office because she is having abdominal pain. She
has been seen for this
problem before. What type of assessment would the nurse do?
Feedback:
A focused assessment is completed by the nurse to gather data about a specific
problem that has already been identified. It is also used to identify new or overlooked
problems.
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A)
To identify a life-threatening problem
B)
To establish a database for medical care
C)
To practice respiratory assessment skills
D)
To facilitate the resident’s ability to breathe
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8.
A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents
begins to choke and is unable to breathe. The nurse assesses the resident’s ability to
breathe and then begins CPR. Why did the nurse assess respiratory
status?
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When a life-threatening physiologic or psychological crisis occurs, the nurse
performs an emergency assessment to identify life-threatening problems. Emergency
assessments are not used to establish a database for medical care, practice assessment
skills, or help a physiologic process (such as breathing).
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9.
A nurse performs an assessment of a client in a long-term care facility and records baseline
data. The nurse reassesses
the client a month later and makes revisions in the plan of care. What type of assessment is the
second assessment?
A)
Comprehensive
B)
Focused
C)
Time-lapsed
D)
Emergency
Ans: C
Feedback:
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The time-lapsed assessment is scheduled to compare a client’s current status to
baseline data obtained earlier. Most clients in residential settings and those receiving
nursing care over longer periods of time, such as homebound clients with visiting
nurses, are scheduled for periodic time-lapsed assessments to reassess health status
and to make necessary revisions in the plan of care.
Of the following information collected during a nursing assessment, which are subjective
data?
A)
vomiting, pulse 96
B)
respirations 22, blood pressure 130/80
C)
nausea, abdominal pain
D)
pale skin, thick toenails
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10.
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Ans: C
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Subjective data are information perceived only by the affected person. They cannot
be perceived or verified by another person. Other terms for subjective data are
symptoms or covert data.
11.
A nurse in the emergency department is completing an emergency assessment for a teenager
just admitted from a car
crash. Which of the following is objective data?
A)
“My leg hurts so bad. I can’t stand it.”
B)
“Appears anxious and frightened.”
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C)
“I am so sick; I am about to throw up.”
D)
“Unable to palpate femoral pulse in left leg.”
Ans: D
Feedback:
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Objective data are observable and measurable data that can be seen, heard, or felt by
someone other than the person experiencing them. Objective data observed by one
person can be verified by another person observing the same client. Objective data
are also called signs or overt data. The only objective data in this question would be
that the nurse is unable to palpate a femoral pulse.
A)
“Can you tell me how long your father has been this way?”
B)
“Sarah, I have to go and read your father’s old charts before we talk.”
C)
“Mr. Koeppe, tell me what you do to take care of yourself.”
D)
“Mr. Koeppe, I know you can’t answer my questions, but it’s okay.”
Ans: C
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12.
A nurse is collecting information from a client with dementia. The client’s daughter
accompanies the client. Which of
the following statements by the nurse would recognize the client’s value as an individual?
Feedback:
Clients such as older adults with dementia, and their children, cannot be relied on to
report accurately. However, they should be encouraged to respond to interview
questions as best as they can. Bypassing the client communicates that the nurse does
not have time or has doubts in the client’s ability to communicate.
13.
A nurse is collecting data from a home care client. In addition to information about the client’s
health status, what is
another observation the nurse should make?
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A)
Number of rooms in the house
B)
Safety of the immediate environment
C)
Frequency of home visits to be made
D)
Friendliness of the client and family
Ans: B
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The nurse should also observe the safety of the immediate environment. Observation
is the conscious and deliberate use of the five senses to gather data. Each time a
client is observed, the nurse observes current responses, ability to provide self-care,
the immediate environment, and the larger environment.
A)
Standing at the end of the bed
B)
Standing at the side of the bed
C)
Sitting at least six feet from the beside
D)
sitting at a 45-degree
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14.
A nurse is preparing to conduct a health history for a client who is confined to bed. How
should the nurse position
herself?
angle to the bed Ans: D
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Feedback:
If the patient is in bed, placing a chair at a 45-degree angle is helpful in facilitating an
easy exchange of information. If the nurse stands at the side or foot of the bed and
physically looks down at the client, a superior–inferior relationship is communicated
and can negatively affect the interview.
A)
“Why didn’t you go to the doctor when you began to have this pain?”
B)
“Are you feeling better now than you did during the night?”
C)
“Tell me more about what caused your pain.”
D)
“If I were you, I would not wait to get medical help next time.”
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15.
Which of the following questions or statements would be appropriate in eliciting further
information when conducting a
health history interview?
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Avoid questions that impede communication during the interview, including those
that can be answered by yes or no, why or how questions, and giving advice.
16.
Which of the following questions or statements would be an appropriate termination of the
health history interview?
A)
“Well, I can’t think of anything else to ask you right now.”
B)
“Can you think of anything else you would like to tell me?”
C)
“I wish you could have remembered more about your illness.”
D)
“Perhaps we can talk again sometime. Goodbye.”
Ans: B
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Feedback:
The successful interview is concluded carefully. After summarizing the data, it is
helpful to ask the client if he or she has anything else to tell the nurse. This gives the
client the chance to add data the nurse did not think to include.
A)
“Do you have a family history of chest problems?”
B)
“Why don’t you use a laxative every night?”
C)
“Do you take anything to help your constipation?”
D)
“Everyone who ages has bowel problems.”
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17.
A nurse is conducting a health history interview for a woman at an assisted-living facility. The
woman says, “I have
been so constipated lately.” How should the nurse respond?
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A possible cause of omission of pertinent data is failing to follow up on cues during
data collection. The nurse should ask about what the client uses to self-treat her
constipation in order to identify further important information. It is not correct to
ignore the statement, ask “why” questions, or make assumptions.
18.
A nurse who collected and organized data during a client history realizes that there is not
enough information to plan
interventions. Which of the following would be the best remedy to prevent this from
happening in the future?
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A)
The nurse should practice interviewing strategies.
B)
The nurse should modify data collection tool.
C)
The nurse should determine specific purpose of data collection.
D)
The nurse should update the database.
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Ans: A
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Strong interviewing skills are needed to obtain the necessary patient data. A common
cause of data omission is the nurse’s failure to know what information is wanted or
not following up on client cues. The nurse only needs to modify the data collection
tool if the database is inappropriately organized. If irrelevant or duplicate data is
collected, the nurse should determine specific purpose of data collection. Data
collection should be ongoing. If the nurse notices that data collection stopped after
the initial assessment data were collected, the nurse should update the database.
What is the primary purpose of validation as a part of assessment?
A)
To identify data to be validated
B)
To establish an effective nurse–client communication
C)
To maintain effective relationships with coworkers
D)
To plan appropriate nursing care
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19.
Ans: D
Feedback:
Validation is the act of confirming or verifying to plan appropriate nursing care.
Validation is an important part of assessment because invalid information can lead to
inappropriate nursing care. Validation does not identify data to be validated, nor does
it establish effective nurse–client communication or relationships with coworkers.
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A)
Blood pressure
B)
Nausea
C)
Heart rate
D)
Respiratory rate
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20.
A client is being prepared for cardiac catheterization. The nurse performs an initial assessment
and records the vital
signs. Which of the following data collected can be classified as subjective data?
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Subjective data are those which the client can feel and describe. Nausea is
subjective data, as it can only be described and not measured. Blood pressure, heart
rate, and respiratory rate are measurable factors and are therefore objective data.
A)
Client’swife
B)
Medical documents
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21.
A client is brought to the emergency department in an unconscious condition. The
client’s wife hands over the previous medical files and points out that the client had
suddenly fallen unconscious after trying to get out of bed. Which of the
following is a primary source of information?
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C)
Test results
D)
Assessment data
Ans: A
Feedback:
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In this case, the primary source of information is the client’s wife, as she can provide
a detailed description of the incident as well as provide the medical history of the
client. The medical files, test results, and assessment data are secondary sources of
information.
A)
Sharp pain in the knee
B)
Small bloody drainage on dressing
C)
Temperature of 102 degrees F
D)
Pulse rate of 90 beats per minute
Ans: A
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22.
The nurse is performing an assessment of a client who has a small wound on the knee,
collecting cues about the client’s
health status. Which of the following would the nurse identify as a subjective cue?
Feedback:
Sharp pain in the knee is an example of a subjective cue. Subjective cues are
imperceptible, immeasurable, and abstract. Small bloody drainage on dressing, a
temperature of 102 degrees F, and a pulse rate of 90 beats per minute are examples of
objective cues.
23.
A nurse caring for a client admitted to the intensive care unit with a stroke assesses the client’s
vital signs, pupils, and
orientation every few minutes. The nurse is performing which type of assessment?
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A)
Initial assessment
B)
Focused assessment
C)
Time-lapsed reassessment
D)
Emergency assessment
Ans: B
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The nurse is performing a focused assessment to determine whether the problem still
exists, and whether the status ofthe problem has changed. An initial or admission
assessment is the initial identification of normal function, functional status, and
collection of data concerning actual or potential dysfunction. Time-lapsed
reassessment is performed after the initial assessment when substantial periods of
time have elapsed between assessments. An emergency assessment is performed any
time a physiologic, psychological, or emotional crisis occurs.
A)
Complete
B)
Focused
C)
General
D)
Time-lapse
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24.
When the nurse inspects a postoperative incision site for infection, which one of the following
types of assessments is
being performed?
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Ans: B
Feedback:
In focused assessments, the nurse determines whether the problem still exists and
whether the status of the problem has changed.
A)
The client’s airway should be assessed.
B)
The nurse should determine the reason for admission.
C)
The nurse should review the client’s medications.
D)
The client’s past medical history is assessed.
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25.
An unconscious patient is brought to the emergency department. Which of the following
assessments should be
implemented first?
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Emergency assessment takes place in life-threatening situations in which the
preservation of life is the top priority. Often, the client’s difficulty involves airway,
breathing, and circulatory problems.
26.
The nurse observes the client as he walks into the room. What information will this provide
the nurse?
A)
Information regarding the client’s gait
B)
Information regarding the client’s personality
C)
Information regarding the client’s psychosocial status
D)
Information on the rate of recovery from surgery
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Ans: A
Feedback:
Observation includes looking, watching, examining, scrutinizing, surveying, scanning, and
appraising.
A)
Auscultation of the lungs
B)
Complaint of nausea
C)
Sensation of burning in her epigastric area
D)
Belief that demons are in her stomach
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27.
After assessment of a client in an ambulatory clinic, the nurse records the data on the
computer. The nurse recognizes
which of the following as objective data?
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Ans: A
Objective data include techniques of inspection, palpation, percussion, and
auscultation. Symptoms, values, perceptions, feelings, beliefs, attitudes, and
sensations are sources of subjective data.
28.
A nurse performing triage in an emergency room makes assessments of clients using critical
thinking skills. Which of
the following are critical thinking activities linked to assessment? Select all that apply.
A)
Carrying out a physician’s order to intubate a client
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B)
Educating a novice nurse on the principles of triage
C)
Using the nursing process to diagnose a blocked airway
D)
Interviewing privately a client suspected of being a victim of abuse
E)
Checking with the family about the data supplied by a client suffering from dementia
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Since the entire nursing process rests on the initial and ongoing assessment of the
client, it is imperative to use excellent critical thinking skills when gathering,
validating, analyzing, and communicating data. The nurse using critical thinking
skills assesses information systematically using the nursing process, detects biases,
makes judgments about the significance of data, and identifies assumptions and
inconsistencies. Carrying out physician’s orders and educating a novice nurse involve
the implementation stage of the nursing process.
Which of the following data regarding a client with a diagnosis of colon cancer are subjective?
Select all that apply.
A)
The client’s chemotherapy causes him nausea and loss of appetite.
B)
The client became teary when his daughter from out of state came to the bedside.
C)
The client’s ileostomy put out 125 mL of effluent in the past four hours.
D)
The patient is unwilling to manipulate or empty his ostomy bag.
E)
The patient has been experiencing fatigue in recent weeks.
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29.
Ans: A, E
Feedback:
Reports of nausea, anorexia, and fatigue are subjective data that depend on the
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client’s self-report. Weeping, ostomy output, and an inability to perform a kinesthetic
task are observable assessment findings that would be characterized as objective.
Which of the following examples of client data needs to be validated? Select all that apply.
A)
A client has trouble reading an informed consent, but states he does not need glasses.
B)
An elderly client explains that the black and blue marks on his arms and legs are due to a fall.
C)
A nurse examining a client with a respiratory infection documents fever and chills.
D)
A client in a nursing home states that she is unable to eat the food being served.
E)
A pregnant client is experiencing contractions that are two minutes apart.
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Because validation of all data is neither possible nor necessary, nurses need to decide
which items need verification. For example, data need to be verified when there are
discrepancies: A patient tells the nurse he is fine and has no concerns, but the nurse
notes that he demonstrates tense body musculature and seems curt in his responses.
When there is a discrepancy between what the person is saying and what the nurse is
observing, validation is necessary to determine accuracy. Data also need verification
when they lack objectivity.
31.
Which of the following are examples of common factors in a client that may influence
assessment priorities? Select all
that apply.
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Diet and exercise program
B)
Standing in the community
C)
Ability to pay for services
D)
Developmental stage
E)
Need for nursing
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Ans: A, D, E
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The purpose for which the assessment is being performed offers the best guideline
about what type and how much data to collect. Assessment priorities are influenced
by the client’s health orientation, developmental stage, culture, and need for nursing.
After the comprehensive nursing assessment has been completed, client health
problems dictate assessment priorities for future nurse–client interactions.
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32.
The nurse is conducting a nursing history of a client with a respiratory rate of 30, audible
wheezing, and nasal flaring.
During the interview, the client denies problems with breathing. What action should the nurse
take next?
A)
Clarify discrepancies of assessment data with the client.
B)
Validate client data with members of the health care team.
C)
Document all data collected in the nursing history and physical examination.
D)
Seek input from family members regarding the client’s breathing at home.
Ans: A
Feedback:
First, the nurse needs to validate the data with the client, who is the primary source.
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The nurse can validate data with the health care provider but consulting with the
client is the best option. The client must give permission for family members to
participate in the health history. Ultimately, the nurse documents all assessment data,
both from the history and the physical exam.
A)
Subjective data
B)
A data cue
C)
An inference
D)
Primary data
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33.
The nurse is reviewing information about a client and notes the following documentation
Client is confused. The nurse
recognizes this information is an example of what?
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Making a judgment that the client is confused is an inference. An inference must be
validated with subjective and/or objective data cues. Sources of data cues can be
primary or secondary.
34.
A)
While bathing the client, the nurse observes the client grimacing. The nurse asks if
the client is experiencing pain. The client nods yes and refuses to continue the bath.
The nurse removes the wash basin, makes the client comfortable, and
documents the event in the client’s chart. Which of the following actions clearly demonstrates
assessing?
The nurse bathing the client
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B)
The nurse documenting the incident
C)
The nurse asking if the client is having pain
D)
The nurse removing the wash basin
Ans: C
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The nurse asking if the client is having pain clearly demonstrates assessing. Bathing
the client and removing the wash basin demonstrate implementation. Documentation
is part of every step of nursing process.
A)
Measure the client’s oral temperature.
B)
Ask a colleague for assistance.
C)
Give the client a clean gown and warm blankets.
D)
Obtain an order for blood cultures
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35.
The nurse has entered a client’s room to find the client diaphoretic (sweat-covered) and
shivering, inferring that the
client has a fever. How should the nurse best follow up this cue and inference?
Ans: A
Feedback:
An inference must be followed by a validation process. In this case, the inference of
fever is best validated or rejected by measuring the client’s temperature. This should
precede interventions such as blood work or even providing a warm blanket.
Chapter 16, Diagnosing
1.
Which of the following is a correct guideline to follow when composing a nursing diagnosis
statement?
A)
Place defining characteristics after the etiology and link them by the phrase “as evidenced by.”
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B)
Phrase the nursing diagnosis as a client need.
C)
Place the etiology prior to the client problem and linked by the phrase “related to.”
D)
Incorporate subjective and judgmental terminology.
Ans: A
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Defining characteristics should follow the etiology and be linked by the phrase “as
evidenced by” when included in the nursing diagnosis. The nursing diagnosis should
be phrased as a client problem or alteration in health state, rather than as a client
need. The client problem precedes the etiology and is linked by the phrase “related
to.” Avoid using judgmental language and write in legally advisable terms.
A)
Ineffective airway clearance as evidenced by inability to clear secretions
B)
Ineffective health maintenance as evidenced by unhealthy habits
C)
Ineffective breathing pattern related to pneumonia
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2.
In planning the care for a client who has pneumonia, the nurse collects data and develops
nursing diagnoses. Which of
the following is an example of a properly developed nursing diagnosis?
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D)
Ineffective therapeutic regimen management due to smoking
Ans: A
Feedback:
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The appropriately written nursing diagnosis is “ineffective airway clearance related
to inability to clear secretions.” “Ineffective health maintenance related to unhealthy
habits” is incorrect because it shows value judgments by the nurse. “Ineffective
breathing pattern related to pneumonia” is incorrectly written because it includes a
medical diagnosis. “Ineffective therapeutic regimen management due to smoking” is
incorrect because the clause “due to” implies a direct cause-and-effect relationship.
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3.
The nurse has identified a number of risk nursing diagnoses in the care of an adolescent who
has been admitted to the
hospital for treatment of an eating disorder. These risk diagnoses indicate which of the
following?
The client is more vulnerable to certain problems than other individuals would be.
B)
The diagnoses present significant risks for the development of medical diagnoses.
C)
The data necessary to make a definitive nursing diagnosis is absent.
D)
The diagnosis has yet to be confirmed by another practitioner.
Ans: A
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A)
Feedback:
Risk nursing diagnoses are clinical judgments that an individual, family, or
community is more vulnerable to develop the problem than others in the same or
similar situation. They do not denote a particular link to medical diagnoses nor do
they require independent confirmation. Missing data is associated with possible
nursing diagnoses.
4.
A client with a new colostomy often becomes short and sarcastic when nurses
attempt to teach him about the management of his new appliance. The nurse has
consequently documented “Noncompliance related hostility” on the
client’s chart. What mistake has the nurse made when choosing and documenting this nursing
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diagnosis?
A)
Presuming to know the factors contributing to the problem
B)
Identifying a problem that cannot be changed
C)
Identifying a problem without corroborating evidence in the statement
D)
Neglecting to identify potential complications related to the problem
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Multiple factors may underlie the client’s response to education in a complex and
emotionally charged situation, such as receiving a new ostomy. As a result, it is likely
presumptuous to ascribe the client’s response to hostility. The problem is likely
modifiable with a correct approach; the evidence underlying a nursing diagnosis is
not normally explicit in the statement itself. The existence of potential complications
is not central to the psychosocial nature of this client’s situation.
A)
Validate the nursing diagnosis
B)
Identify potential complications
C)
Cross-reference the nursing diagnosis with medical diagnoses
D)
Modify interventions based on the diagnosis
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5.
The nurse has drafted a nursing diagnosis of Imbalanced Nutrition: More Than Body
Requirements in the care of
moderately obese client. How should the nurse proceed after writing this diagnosis?
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Ans: A
Feedback:
After writing a nursing diagnosis, it is important to verify and validate the diagnosis.
This action should precede the modification of the client’s care. Nursing diagnoses
do not always correlate with medical diagnoses and not every nursing diagnosis is
accompanied by potential complications.
Which of the following provides the nurse with the most reliable basis on which to choose a
nursing diagnosis?
A)
A cluster of several significant cues of data that suggest a particular health problem
B)
A single, definitive cue that is closely associated with a common diagnosis
C)
A cue that can be verified by objective, medical data
D)
A group of related nursing diagnoses that exist within the same NANDA-approved domain
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A data cluster is a grouping of client data or cues that points to the existence of a
client health problem. Nursing diagnoses should always be derived from clusters of
significant data rather than from a single cue. Medical corroboration is not always
possible or necessary. The presence of multiple nursing diagnoses within one
domain does not necessarily validate further diagnoses in that same domain.
7.
In addition to identifying responses to actual or potential health problems, what is another
purpose of the diagnosing step
in the nursing process?
A)
To collect information about subjective and objective data
B)
To correlate nursing and medical diagnostic criteria
C)
To identify etiologies of health problems
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D)
To evaluate mutually developed expected outcomes
Ans: C
Feedback:
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The purpose of diagnosing, the second step in the nursing process, is to identify how
an individual, a group, or a community responds to actual or potential health and life
processes; to identify etiologies (factors that contribute to or cause health problems);
and to identify resources or strengths that the individual, group, or community can
draw on to prevent or resolve problems.
Which of the following client care concerns is clearly a nursing responsibility?
A)
Prescribing medications
B)
Monitoring health status changes
C)
Ordering diagnostic examinations
D)
Performing surgical procedures
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8.
Feedback:
Monitoring for health status changes is clearly a nursing responsibility. The other
options are medical responsibilities, although in some instances an advanced practice
nurse practitioner may be responsible for A and C.
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A)
Selecting nursing interventions to meet expected outcomes
B)
Establishing a database of information for future comparison
C)
Mutually establishing desired outcomes of the plan of care
D)
Evaluating the effectiveness of the established plan of care
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9.
After completing assessments, a nurse uses the data collected to identify appropriate nursing
diagnoses for a client. For
what are the nursing diagnoses used?
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The nurse formulates, validates, and lists nursing diagnoses for each client. Nursing
diagnoses provide the basis for selecting nursing interventions that will achieve
valued client outcomes for which the nurse is responsible.
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10.
Which of the following statements accurately describes the legal responsibility of the nurse
making a diagnosis for a
client?
B)
The nurse may make a diagnosis, but the physician is responsible for making sure it is
appropriate for the client.
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A)
The nurse practitioner is responsible for making all nursing diagnoses and determining if they
are appropriate for the
client.
C)
The nurse must decide if he or she is qualified to make a nursing diagnosis and will accept
responsibility for treating it.
D)
The health care facility directs the nursing diagnosis in order to receive payment for services
performed.
Ans: C
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Feedback:
The term diagnosis means there is a problem requiring qualified treatment. The nurse
must decide if he or she is qualified to make the diagnosis and will be able to treat it.
If not, the nurse must refer the client to a qualified person for treatment.
A)
Neither appendicitis nor acute pain
B)
Both appendicitis and acute pain
C)
Appendicitis
D)
Acute pain
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11.
A student is reviewing a client’s chart before giving care. She notes the following diagnoses in
the contents of the chart:
“appendicitis” and “acute pain.” Which of the diagnoses is a medical diagnosis?
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Medical diagnoses identify diseases (in this case, appendicitis). Nursing diagnoses
describe problems treated by the nurse within the scope of independent nursing
practice.
12.
A nurse develops a plan of care to meet the needs of a client who has had a large loss
of blood after a snowmobile crash. Intravenous fluids and blood are administered and
the nurse monitors the client’s physiologic response. This action is
known as a:
A)
medical diagnosis.
B)
nursing diagnosis.
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C)
collaborative problem.
D)
goal for care.
Ans: C
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Collaborative problems are certain physiologic complications that nurses monitor to
detect onset or changes in status. Nurses manage collaborative problems by using
physician-prescribed and nursing-prescribed interventions to minimize the
complications of the event.
A)
“I often have diarrhea after I eat spicy foods.”
B)
“My skin is so dry I just can’t keep from scratching.”
C)
“I get out of breath when I walk a few steps.”
D)
“I just feel so bad about myself these days.”
Ans: C
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13.
A nurse is reviewing the health history and physical assessment findings for a client
who is having respiratory problems. Of the following data collected, what data from
the health history would be a cue to a nursing diagnosis for this
problem?
Feedback:
Most experienced nurses begin the work of interpreting and analyzing data while
they are still collecting it. The term cue is often used to denote significant data,
which “raises a red flag” to look for patterns or clusters of datathat
signal a nursing diagnosis. In this instance, the client’s statement of getting out of
breath when walking would be a cue to assess other subjective and objective data
related to the respiratory system.
14.
What is the focus of a diagnostic statement for a collaborative problem?
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A)
The client problem
B)
The potential complication
C)
The nursing diagnosis
D)
The medical diagnosis
Ans: B
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To write a diagnostic statement for a collaborative problem, the nurse should focus on
the potential complications of the problem and use “PC” (for potential complication),
followed by a colon, and list the complications that might occur. For clarity, the nurse
should link the potential complications and the collaborative problem by using “related
to.”
A)
Trust clinical judgment and experience over asking for help.
B)
Respect clinical intuition, but never allow it to determine a diagnosis.
C)
Recognize personal biases as a strength in formulating diagnoses.
D)
Keep an open mind and trust your intuition when formulating diagnoses.
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15.
Successful implementation of each step of the nursing process requires high-level skills in
critical thinking. Which of the
following statements accurately describe a guideline for using this process?
Ans: D
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Feedback:
To correctly diagnose health problems, the nurse must be familiar with nursing
diagnoses and other health problems; read professional literature and keep reference
guides handy; trust clinical experience and judgment but be willing to ask for help
when the situation demands more than his or her qualifications and experience can
provide; respect clinical intuitions, but before writing a diagnosis without evidence,
increase the frequency of observations and continue to search for clues to verify
intuition. The nurse must also recognize personal biases and keep an open mind.
A)
Nothing; this observation is not important.
B)
The mother is just behaving as all mothers do.
C)
A baby is not capable of having strengths.
D)
Nurturing is a strength for developing infants.
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16.
A nurse observes a new mother tenderly holding and softly talking to her baby. What does this
observation tell the nurse
about the baby’s strengths?
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Ans: D
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A strength, as assessed by the nurse during data interpretation and analysis,
contributes to a client’s level of wellness. In this case, the obvious love of the mother
for her baby indicates a significant strength in the normal growth and development of
the baby.
17.
A nurse completes a health history and physical assessment for an adolescent before
he begins football practice. Based on findings, the nurse recommends reinforcing
good health habits. What conclusion did the nurse reach after interpreting
and analyzing the data?
A)
No problem
B)
Possible problem
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C)
Actual problem
D)
Clinical problem
Ans: A
Feedback:
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The nurse reaches one of four basic conclusions after interpreting and analyzing the
client data. Different nursing responses are possible for each conclusion. In this case,
the nurse would most likely conclude there was no problem and reinforce the client’s
health habits.
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No problem
B)
Possible problem
C)
Actual problem
D)
Clinical problem
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18.
A nurse caring for an older adult client in a long-term care facility notices that the bedding is
wet when the client gets up
in the morning. The nurse collects more data to form a conclusion. What type of problem is
involved in this scenario?
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The nurse reaches one of four basic conclusions after interpreting and analyzing the
client data: no problem, possible problem, actual or potential problem, or clinical
problem. When dealing with a possible problem, the nurse must collect more data to
confirm or disprove a suspected problem.
A)
“needs nasal oxygen to improve breathing”
B)
“cough related to ineffective airway clearance”
C)
“ineffective airway clearance related to thick mucus”
D)
“refuses to cough and expectorate thick mucus”
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19.
A nurse is formulating a nursing diagnosis for a client with a respiratory disease. Which of the
following would be
correct?
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It is important to use guidelines to formulate correctly written nursing diagnoses. The
nurse would not use client needs, put defining characteristics before the diagnoses, or
judge the willingness of the client to cough.
20.
A nurse writes the following nursing diagnosis for a client with Alzheimer’s disease:
Disturbed Thought Processes related to Alzheimer’s disease as evidenced by
incoherent language. Which part of this diagnosis is considered the
problem statement?
A)
disturbed thought processes
B)
related to
C)
Alzheimer’s disease
D)
incoherent language
Ans: A
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The purpose of the problem statement is to describe the health state or health problem
of the client as clearly and concisely as possible. Because this section of the nursing
diagnosis identifies what is unhealthy about the client and what the client would like
to change in his or her health status, it suggests client outcomes. NANDA
recommends the use of quantifiers or descriptors to limit or specify the meaning of a
problem statement. Disturbed thought processes is a NANDA-approved descriptor for
this client problem. The etiology identifies the physiologic, psychological, sociologic,
spiritual, and environmental factors believed to be related to the problem as either a
cause or a contributing factor, and in this case is Alzheimer’s disease. Incoherent
language is considered a defining characteristic or subjective/objective data signaling
the existence of an actual or potential health problem.
A)
Post-trauma syndrome related to being attacked
B)
Psychological overreaction related to being attacked
C)
Needs assistance coping with attack
D)
Mental distress related to being attacked
Ans: A
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21.
A nurse is formulating a diagnosis for a client who is reliving a brutal mugging that
took place several months ago. The client is crying uncontrollably and states that he
“can’t live with this fear.” Which of the following diagnoses for this
client is correctly written?
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Post-trauma syndrome is a NANDA-approved problem statement and being attacked is the correct etiology.
Overreaction and mental distress implies a value judgment by the nurse. Needs
assistance addresses the need of the client.
Of the following types of nursing diagnoses, which one is validated by the presence of major
defining characteristics?
A)
Risk nursing diagnosis
B)
Actual nursing diagnosis
C)
Possible nursing diagnosis
D)
Wellness diagnosis
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Actual nursing diagnoses represent problems that have been validated by the presence
of major defining characteristics. An actual nursing diagnosis has four components:
label, definition, defining characteristics, and related factors.
A)
The expected outcome of the plan of care
B)
A cue to determining a health problem
C)
The major defining characteristic of a health problem
D)
The health state or problem of the client
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23.
A nursing diagnosis is written as Disturbed Self-Esteem related to presence of large scar over
left side of face. What
does the phrase “Disturbed Self-Esteem” identify?
Ans: D
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Post-trauma syndrome is a NANDA-approved problem statement and being attacked is the correct etiology.
The problem, a part of a nursing diagnosis, describes the health state or health
problem of the client as clearly and concisely as possible. It identifies what is
unhealthy about the client and what the client would like to change. It also suggests
client outcomes but is not an outcomes statement.
A)
Etiology
B)
Problem
C)
Defining characteristics
D)
Client need
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24.
In the nursing diagnosis Disturbed Self-Esteem related to presence of large scar over left side
of face, what part of the
nursing diagnosis is “presence of large scar over left side of face”?
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The etiology identifies the physiologic, psychological, sociologic, spiritual, and
environmental factors believed to be related to the problem as either a cause or a
contributing factor. The etiology directs nursing interventions.
25.
A student identifies Fatigue as a health problem and nursing diagnosis for a client receiving
home care for treatment of
metastatic cancer. What statement or question would be best to validate this client problem?
A)
“I have assessed you and find you are fatigued.”
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B)
“I analyzed and interpreted your information as fatigue.”
C)
“Why are you so tired all the time?”
D)
“I think fatigue is a problem for you. Do you agree?”
Ans: D
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After a tentative nursing diagnosis is made, it should be validated. Clients who are
able to participate in decision making should be encouraged to validate the diagnosis.
Of all the benefits of using nursing diagnoses, which one is probably the most important to
nurses?
A)
Defining the domain of nursing practice
B)
Informing patients of their care
C)
Improving communication among nurses
D)
Structuring curricular content
Ans: C
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26.
Feedback:
Although all the choices are correct, improved communication among nurses and
other health care professionals is probably the most important benefit that accurate,
up-to-date nursing diagnoses offer nurses.
27.
According to Maslow’s hierarchy of needs, which nursing diagnosis has the lowest priority for
a client admitted to the
intensive care unit with a diagnosis of congestive heart failure?
A)
Ineffective airway clearance
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B)
Ineffective coping
C)
Impaired urinary elimination
D)
Risk for body image disturbance
Ans: D
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Risk for disturbed body image is the least priority among all the nursing diagnoses
mentioned, according to the Maslow’s hierarchy. Body image disturbance is not
vital for life. Secondly, it is a potential diagnosis, not an actual diagnosis. The other
options could be an actual diagnosis present in the client. Ineffective airway
clearance is the most important diagnosis because it is vital to life. Impaired urinary
elimination is the next most important diagnosis because it is a physiological need.
Ineffective coping is a social need, followed by the least important diagnosis of
disturbed body image.
A)
Impaired physical mobility
B)
Disturbed body image
C)
Risk for infection
D)
Risk for social isolation
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28.
A client has an external fixation device on his leg due to a compound fracture. The
client says that the device and swelling makes his leg look ugly. Which nursing
diagnosis should the nurse document in his care plan based on the
client’s concern?
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Ans: B
Feedback:
The diagnosis of disturbed body image is appropriate for the client because he is
worried about the appearance of his legs due to swelling and the external fixation
device. There is no mention about impaired physical mobility or risk for social
isolation in the client’s concern. There may be a risk of infection, but the client does
not mention it.
A)
Risk for impaired physical mobility due to surgery
B)
Ineffective denial related to poor coping mechanisms
C)
Disturbed body image related to the incision scar
D)
Risk of injury related to surgical outcomes
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29.
A client who has to undergo a parathyroidectomy is worried that he may have to wear a scarf
around his neck after
surgery. What nursing diagnosis should the nurse document in the care plan?
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Ans: C
Feedback:
The client is concerned about the surgery scar on his neck, which would disturb his
body image; therefore, the appropriate diagnosis should be disturbed body image
related to the incision scar. Risk for impaired physical mobility may be present after
surgery, but is not related to the concerns expressed by the client. Likewise,
ineffective denial related to poor coping mechanisms, and injury related to surgical
outcomes are also not related to the client’s concern.
30.
A nurse who is caring for an unresponsive client formulates the nursing diagnosis,
“Risk for Aspiration related to reduced level of consciousness.” The nurse
documents this nursing diagnosis as correct based on the understanding that
which of the following is a characteristic of this type of diagnosis?
A)
Is written as a two-part statement
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B)
Describes human response to a health problem
C)
Describes potential for enhancement to a higher state
D)
Made when not enough evidence supports the problem
Ans: A
Feedback:
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The risk diagnoses are written as two-part statements because they do not include
defining characteristics. An actual nursing diagnosis describes human response to a
health problem. Wellness diagnoses describe potential for enhancement to a higher
state. A possible nursing diagnosis is made when not enough evidence supports the
problem.
A)
Impaired urinary elimination
B)
Readiness for enhanced sleep
C)
Risk for infection
D)
Possible impaired adjustment
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31.
After assessing a client, the nurse formulates several nursing diagnoses. Which of the
following would the nurse identify
as an actual nursing diagnosis?
Ans: A
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Impaired urinary elimination is an actual nursing diagnosis because it describes a
human response to a health problem that is being manifested. Readiness for enhanced
sleep is a wellness diagnosis. Risk for infection is a risk diagnosis, and possible
impaired adjustment is a possible nursing diagnosis.
What is the nurse accountable for, according to the state nurse practice act?
A)
Continuing education
B)
Nursing diagnoses
C)
Prescribing medications
D)
Mentoring other nurses
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32.
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State nurse practice acts have included diagnosis as part of the domain of nursing
practice for which nurses are held accountable.
A client is experiencing shortness of breath, lethargy, and cyanosis. These three cues provide
organization or …
A)
Categorizing
B)
Diagnosing
C)
Grouping
D)
Clustering
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Ans: D
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Cue clustering brings together cues that if viewed separately would not convey the same
meaning.
34.
The nurse is providing care for a client who experienced an ischemic stroke five days ago.
Which of the following
diagnoses would the nurse be justified in identifying and documenting in the care of this
client? Select all that apply.
Dysphagia
B)
Bowel Incontinence
C)
Impaired Swallowing
D)
Impaired Physical Mobility
E)
Risk for Hemiparesis
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Bowel Incontinence, Impaired Swallowing, and Impaired Physical Mobility are all
health problems that can be independently prevented or resolved by nursing practice.
Dysphagia and hemiparesis are medical diagnoses.
35.
Which of the following reflects the diagnosis phase?
A)
The nurse identifies that the client does not tolerate activity.
B)
The nurse performs wound care using sterile technique.
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C)
The nurse sets a tolerable pain rating with the client.
D)
The nurse documents the client’s response to pain medication.
Ans: A
Feedback:
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Recognition of a client health problem that can be prevented or resolved by
independent nursing intervention, such as activity intolerance, is the focus of
diagnosing. Performing wound care is an example of implementation. Setting a
tolerable pain rating with the client is an example of planning. Documenting the
client’s response to pain medication is an example of evaluation.
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Chapter 17, Outcome Identification and Planning
A)
Client returns home verbalizing an understanding of contributing factors, medications, and
signs and symptoms of an
asthma attack.
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1.
The nurse develops long-term and short-term outcomes for a client admitted with asthma.
Which of the following is an
example of a long-term goal?
By day 3 of hospitalization, the client verbalizes knowledge of factors that exacerbate the
symptoms of asthma.
C)
Within one hour of a nebulizer treatment, adventitious breath sounds and cough are decreased.
D)
Within 72 hours of admission, the client’s respiratory rate returns to normal and retractions
disappear.
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B)
Ans: A
Feedback:
An example of a long-term outcome is “Patient returns home verbalizing an
understanding of contributing factors, medications, and signs and symptoms of an
asthma attack.” The other three examples are short-term outcomes that focus on
short-term goals related to the period of time during hospitalization.
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A)
The nurse expresses the client outcome as a nursing intervention.
B)
The nurse develops measurable outcomes using verbs that are observable.
C)
The nurse develops a target time when the client is expected to achieve that outcome.
D)
The outcome should include a subject, verb, conditions, performance criteria, and target time.
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2.
Nurses make common errors in the identification and development of outcomes. Which of the
following is a common
error made when writing client outcomes?
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Ans: A
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A common error made when writing client outcomes includes the nurse expressing
the client outcome as a nursing intervention. The other mentioned criteria for writing
client outcomes are correct.
A)
Reduction in the time spent on care planning
B)
Increased autonomy related to the nursing care planning process
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3.
Increasingly, health care institutions are implementing computerized plans of nursing care. A
benefit of using
computerized plans includes which of the following?
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C)
Enhanced individualization of a care plan
D) Increased nursing expertise in care planning
Ans: A
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The benefits of using computerized plans include ready access to a large knowledge
base; improved record keeping, with resultant improvement in audits and quality
assurance; documentation by all members of the health care team; and reduced time
spent on paperwork. Research cautions that computerized systems for client care
planning contribute to loss of autonomy, loss of individualization of care, and loss of
nursing expertise.
A)
Psychomotor
B)
Affective
C)
Cognitive
D)
Holistic
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4.
The nurse is planning the care of a male client who is receiving treatment for acute
renal failure and who has begun dialysis three times weekly. The nurse has identified
the following outcome: “Client will demonstrate the appropriate
care of his arteriovenous fistula.” This outcome is classified as which of the following?
Feedback:
Psychomotor outcomes describe the client’s achievement of new skills, such as the
safe and aseptic care of a new fistula. Cognitive outcomes are focused on knowledge
and effective outcomes address values, beliefs, and attitudes. Outcomes are not
classified as holistic.
The nurse is caring for a client who has been newly diagnosed with diabetes. One of
the outcomes the nurse read on the client’s plan of care this morning was: “Client will
demonstrate correct technique for self-injecting insulin.” The client required insulin
prior to his lunch and successfully drew up and administered his insulin while the
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Enhanced individualization of a care plan
5.
nurse observed. How
should the nurse follow up this observation?
A)
Record an evaluative statement in the client’s plan of care.
B)
Remove the outcome from the client’s care plan.
C)
Ask the nurse who wrote the plan of care to document this development.
D)
Reassess the client’s psychomotor skills at dinner time.
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C)
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The client has successfully met this outcome, and the nurse should note the time and
date that it was achieved in the client’s plan of care. The outcome should not be
removed from the plan of care and it is unnecessary to have the original author of the
plan update it. Further observation may or may not be necessary at dinner time, but an
evaluative statement should nonetheless be recorded at the present time.
A)
“I’m not interested one bit in wearing an artificial hand.”
B)
“I’m worried that I’m going to get some really strange looks when I wear this thing.”
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6.
A male client is scheduled to be fitted with a prosthesis following the loss of his
nondominant hand in a farm accident several weeks earlier. Nurses have documented
the following outcome during this stage of his care: “After attending an educational
session, client will demonstrate correct technique for applying his prosthesis.” Which
of this client’s
following statements would signal a need to amend this outcome?
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C)
“I don’t have a clue how this thing goes on and comes off.”
D)
“I don’t understand the technology that’s used in this artificial hand.”
Ans: A
Feedback:
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It is imperative that interventions and outcomes be valued by the client. The client’s
resistance to using a prosthesis likely invalidates the outcome that addresses his
technique for its use. The other statements express cognitive and affective learning
needs that would need to be addressed, but none of those precludes his eventual
mastery of the prosthesis.
What is the primary purpose of the outcome identification and planning step of the nursing
process?
A)
To collect and analyze data to establish a database
B)
To interpret and analyze data so as to identify health problems
C)
To write appropriate client-centered nursing diagnoses
D)
To design a plan of care for and with the client
Ans: D
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7.
Feedback:
The primary purpose of outcome identification and planning is to design a plan of
care for (and with) the client that, once implemented, results in the prevention,
reduction, or resolution of client health problems and the attainment of the client’s
health expectations, as identified in the client outcomes.
8.
Critical thinking is an essential component in all phases of the nursing process. What question
might be used to facilitate
critical thinking during outcome identification and planning?
A)
“How do I best cluster these data and cues to identify problems?”
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B)
“What problems require my immediate attention or that of the team?”
C)
“What major defining characteristics are present for a nursing diagnosis?”
D)
“How do I document care accurately and legally?”
Ans: B
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Questions to facilitate critical thinking during outcome identification and planning
include those related to setting priorities, such as “Which problems require my
immediate attention or that of the team?” and “Which problems are most important to
the client?”
A nurse is discharging a client from the hospital. When should discharge planning be initiated?
A)
At the time of discharge from an acute health care setting
B)
At the time of admission to an acute health care setting
C)
Before admission to an acute health care setting
D)
When the client is at home after acute care
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Ans: B
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Discharge planning is best carried out by the nurse who worked most closely with the
client and family. In acute care settings, comprehensive discharge planning begins
when the client is admitted for treatment.
A)
Physiologic
B)
Safety
C)
Love and belonging
D)
Self-actualization
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10.
The nursing diagnosis Impaired Gas Exchange, prioritized by Maslow’s hierarchy of basic
human needs, is appropriate
for what level of needs?
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Because basic human needs must be met before a person can focus on higher-level
needs, client needs may be prioritized according to Maslow’s hierarchy. Physiologic
needs, including the need for oxygen, are the most basic and have the highest priority.
11.
A resident of a long-term care facility refuses to eat until she has had her hair combed and her
make-up applied. In this
case, what client need should have priority?
A)
The need to have nutrition
B)
The need to feel good about oneself
C)
The need to live in a safe environment
D)
The need for love from others
Ans: B
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Feedback:
When setting priorities, it is best to first meet the needs that the client believes are
most important. In this situation, the woman is not refusing food altogether; rather,
she wants to feel good about herself (self-esteem) when she does eat.
During outcome identification and planning, from what part of the nursing diagnoses are
outcomes derived?
A)
The defining characteristics
B)
The related factors
C)
The problem statement
D)
The database
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Outcomes are derived from the problem statement of the nursing diagnosis. For each
nursing diagnosis, at least one outcome should be written that, if achieved,
demonstrates a direct resolution of the problem statement.
13.
A nurse is developing outcomes for a specific problem statement. What is one of the most
important considerations the
nurse should have?
A)
The written outcomes are designed to meet nursing goals
B)
To encourage the client and family to be involved
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C)
To discourage additions by other healthcare providers
D)
Why the nurse believes the outcome is important
Ans: B
Feedback:
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One of the most important considerations in writing outcomes is to encourage the
client and family to be involved in goal development as their abilities and interest
permit. The more involved they are, the greater the probability the goals will be
achieved.
Which of the following outcomes is correctly written?
A)
Abdominal incision will show no signs of infection.
B)
On discharge, client will be free of infection.
C)
On discharge, client will be able to list five symptoms of infection.
D)
During home care, nurse will not observe symptoms of infection.
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14.
Feedback:
To be measurable, outcomes should have a subject (client or part of the client), verb
(action to be performed), conditions (not always included), performance criteria
(observable, measurable), and target time (to achieve the outcome).
15.
Which of the following illustrates a common error when writing client outcomes?
A)
Client will drink 100 mL of fluid every 2 hours from 6 a.m. to 9 p.m.
B)
Client will demonstrate correct sequence of exercises by next office visit.
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C)
Client will be less anxious and fearful before and after surgery.
D)
On discharge, client will list five symptoms of infection to report.
Ans: C
Feedback:
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Common errors when writing client outcomes include expressing the outcome as a
nursing intervention, using verbs that are not observable and measurable (as is done
here), and writing vague outcomes (also done here).
Which of the following groups of terms best describes a nurse-initiated intervention?
A)
Dependent, physician-ordered, recovery
B)
Autonomous, clinical judgment, client outcomes
C)
Medical diagnosis, medication administration
D)
Other health care providers, skill acquisition
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Feedback:
A nursing intervention is any treatment, based on clinical judgment and knowledge,
that a nurse performs to enhance client outcomes. Nurse-initiated interventions are
autonomous (independently performed).
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What part of the nursing diagnosis statement suggests the nursing interventions to be included
in the plan of care?
A)
Problem statement
B)
Defining characteristics
C)
Etiology of the problem
D)
Outcomes criteria
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In contrast to the client goals, which are suggested by the problem statement of the
diagnosis, it is the cause of the problem (etiology) that suggests the nursing
interventions. Effective nurses select nursing interventions that specifically address
factors that cause, or contribute to, the client’s problem.
A)
Kardex care plans
B)
Computerized plans of care
C)
Clinical pathways
D)
Student care plans
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18.
What name is given to tools that are used to communicate a standardized interdisciplinary plan
of care for clients within
a case management health care delivery system?
Ans: C
Feedback:
Clinical pathways (critical pathways, CareMaps) are tools used to communicate the
standardized interdisciplinary plan of care for clients. The emphasis in case
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management is on clearly stating expected client outcomes and the specific times
targeted to achieve these outcomes.
19.
A nurse has developed a plan of care with nursing interventions designed to meet specific
client outcomes. The
outcomes are not met by the time specified in the plan. What should the nurse do now in terms
of evaluation?
Continue to follow the written plan of care.
B)
Make recommendations for revising the plan of care.
C)
Ask another health care professional to design a plan of care.
D)
State “goal will be met at a later date.”
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Client outcomes are meaningless unless the nurse evaluates the client’s progress
toward their achievement. If the plan is not achieved (not met), recommendations for
revising the plan of care are included in the evaluative statement.
A)
Kardex
B)
Case management
C)
Critical pathways
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20.
Which of the following types of care plans is most likely to enable the nurse to take a holistic
view of the client’s
situation?
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D)
Concept map care plan
Ans: D
Feedback:
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A concept map care plan is a diagram of client problems and interventions. The nurse’s
ideas about client problems and treatments are the “concepts” that are diagrammed.
These maps are used to organize client data, analyze relationships in the data, and
enable the nurse to take a holistic view of the client’s situation (Schuster, 2002).
Which of the following is an example of a well-stated nursing intervention?
A)
Client will drink 100 mL of water every 2 hours while awake.
B)
Offer client 100 mL of water every 2 hours while awake.
C)
Offer client water when he complains of thirst.
D)
Client will continue to increase oral intake when awake.
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Ans: B
Nursing interventions describe in writing the specific nursing care to be implemented
for the client. They include information that answers the questions who, what, where,
when, and how.
22.
What common problem is related to outcome identification and planning?
A)
Failing to involve the client in the planning process
B)
Collecting sufficient data to establish a database
C)
Stating specific and measurable outcomes based on nursing diagnoses
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D)
Writing nursing orders that are clear and resolve the problem
Ans: A
Feedback:
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One of the most important considerations in outcome achievement is to encourage
the client and family to be as involved in goal development as their abilities and
interest permit. The more involved they are, the greater the probability that the
outcomes will be achieved.
A)
Assessment skills
B)
Nursing books
C)
Client’s records
D)
Supervisor’s advice
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23.
A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to
the health care facility. The
nurse determines the client’s priorities for care using which of the following?
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Feedback:
The nurse should use assessment skills to determine the priority of nursing care for
the client. Books on nursing can give only the theoretical aspect of nursing care.
Client’s records reveal information about the client’s condition but do not convey the
client’s needs. Advice from supervisors can be taken if confronted with a problem.
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A)
Evaluate the need for antibiotics.
B)
Resolve the client’s anxiety.
C)
Provide preoperative education.
D)
Prepare the client for surgery.
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24.
A client is scheduled for surgery for an abdominal hysterectomy. During the preoperative
assessment, the client states, “I
am very nervous and scared to have surgery.” What client outcome is the priority?
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A priority is something that takes precedence in position, deemed the most important
among several items. The client’s preparation for surgery is important, but to have a
successful outcome, the nurse must address the psychosocial issues related to anxiety.
Which of the following client outcomes best describes the parameters for achieving the
outcome?
A)
The client will eat a well-balanced diet.
B)
The client will consume a 2,400-calorie diet, with three meals and two snacks, starting
tomorrow.
C)
The client will cleanse his wound with soap and water and apply a dry sterile dressing.
D)
The client will be without pain in 24 hours.
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25.
Ans: B
Feedback:
The client will consume a 2,400-calorie diet, with three meals and two snacks,
starting tomorrow possesses all parameters for achieving the outcome.
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Professional physicians’ organizations
B)
State Nurse Practice Acts
C)
The Joint Commission
D)
The Agency for Health Care Research and Quality
E)
The Patient Health Partnership
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A)
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26.
Nurses identifying outcomes and related nursing interventions must refer to the
standards and agency policies for setting priorities, identifying and recording
expected client outcomes, selecting evidence-based nursing interventions, and
recording the plan of care. Which of the following are recognized standards? Select all that
apply.
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To plan health care correctly, the nurse must be familiar with standards and agency
policies for setting priorities, identifying and recording expected client outcomes,
selecting evidence-based nursing interventions, and recording the plan of care. These
standards include the law, national practice standards, specialty professional nursing
organizations, The Joint Commission, the Agency for Health Care Research and
Quality, and employers.
27.
In which of the following clients has the order of priorities for nursing diagnoses changed?
Select all that apply.
A)
A client in a long-term care facility who had a stroke
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B)
A client who is recovering from a broken leg
C)
A client who insists on using the bathroom instead of a bedpan
D)
A client who appears confused after taking pain medication
E)
A pregnant client whose contractions are progressing as anticipated
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Ans: A, C, D
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The work of setting priorities demands careful critical thinking. When planning
nursing care, the nurse should consider the following: Have changes in the client’s
health status influenced the priority of nursing diagnoses? Have changes in the way
the client is responding to health and illness (or the plan of care) affected those
nursing diagnoses that can be realistically addressed? Are there relationships among
diagnoses that require that one be worked on before another can be resolved? Do
several client problems need to be dealt with together.
A)
They demonstrate the impact that nurses have on the system of health care delivery.
B)
They standardize and define the knowledge base for nursing curricula and practice.
C)
They limit the number of appropriate nursing interventions to be selected.
D)
They hinder the teaching of clinical decision making to novice nurses.
E)
They enable researchers to examine the effectiveness and cost of nursing care.
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28.
Which of the following statements accurately describes the impact on nursing of using
NIC/NOC standardized
languages? Select all that apply.
Ans: A, B, E
Feedback:
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Using NIC/NOC standardized language demonstrates the impact that nurses have on
the system of health care delivery; standardizes and defines the knowledge base for
nursing curricula and practice; facilitates the selection of appropriate nursing
interventions; facilitates the teaching of clinical decision making to novice nurses;
enables researchers to examine the effectiveness and cost of nursing care; assists
educators to develop curricula that better articulate with clinical practice; assists
administrators in planning more effectively for staff and equipment needs; promotes
the development and use of nursing information systems; and communicates the
nature of nursing to the public.
Which of the following is a correctly written client goal? Select all that apply.
A)
The client will identify five low-sodium foods by October 9.
B)
The client will know the signs and symptoms of infection.
C)
The client will rate pain as a 3 or less on a 10-point scale by 5 pm today.
D)
The client will understand the side effects of digoxin (Lanoxin).
E)
The client will eat at least 75% of all meals by May 5.
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29.
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Ans: A, C, E
Outcomes are client-centered, use action verbs, identify measurable criteria, and
include a time frame as to when the outcome should be achieved. A correctly written
outcome will identify who (the client) will do what (eat), how well (75%) under what
circumstances (not always included), and by when (May 5). Understand and know are
vague and are not action-oriented.
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Which intervention does the nurse recognize as a collaborative intervention?
A)
Teach the client how to walk with a three-point crutch gait.
B)
Administer spironolactone (Aldactone).
C)
Perform tracheostomy care every eight hours.
D)
Straight catheterize every six hours.
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Collaborative interventions are treatments initiated by other providers, such as
pharmacists, respiratory therapists, physical therapists, and other members of the
health care team. Teaching the client how to walk with crutches would be a
collaborative intervention. Administering medications, performing tracheostomy
care, and catheterizing a client require a physician’s order and are physician-initiated
interventions.
Which of the following is a correctly written client goal?
A)
The client will eliminate a soft formed stool.
B)
The client understands what foods are low in sodium.
C)
The client will ambulate 10 feet with a walker by October 12.
D)
The client correctly self-administers the morning dose of insulin.
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31.
Ans: C
Feedback:
Outcomes are client-centered, use action verbs, identify measureable criteria, and
include a time frame as to when the outcome should be achieved. A correctly
written outcome will identify who (the client) will do what (ambulate), how well
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(10 feet), under what circumstances (with a walker), and by when (October 12).
Understand is vague and not action-oriented. The outcomes regarding eliminating a
stool and self-administering insulin are missing the time frame.
A)
Teach client how to transfer from bed to chair and chair to bed.
B)
Administer oxygen 4 L/min per nasal cannula.
C)
Assist the client with coughing and deep breathing every hour.
D)
Monitor intake and output every 2 hours.
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32.
The nursing student asks the nurse about nurse-initiated and physician-initiated interventions.
Which of the following is
a physician-initiated intervention?
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A physician-initiated intervention is an intervention initiated by a physician in
response to a medical diagnosis but carried out by a nurse in response to a
physician’s order. A physician’s order is required for the nurse to administer drugs,
such as oxygen. A nurse-initiated intervention is an autonomous action based on
scientific rationale that a nurse executes to benefit the client in a predictable way
related to the nursing diagnosis and expected outcomes. Nursing- initiated
interventions, such as teaching client how to transfer, assisting with coughing and
deep breathing, and monitoring intake and output do not require a physician’s order.
33.
The nurse formulates the following client outcome: Client will correctly draw up morning
dose of insulin and identify
four signs and symptoms of hypoglycemia by September 7. Which error has the nurse made?
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A)
Expressed the client outcomes as a nursing intervention
B)
Wrote vague outcomes that will confuse other nurses
C)
Included more than one client behavior in the outcome
D)
Used verbs that are not observable and measurable
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Ans: C
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Two client behaviors have been included in the outcome statement: drawing up
insulin and identifying four signs and symptoms.
Which of the following is not appropriate in writing client-centered measurable outcomes?
A)
The client or a part of the client
B)
A flexible time frame
C)
Observable, measurable terms
D)
The action the client will perform
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34.
Ans: B
Feedback:
In writing client-centered measurable outcomes, a target time is required. This target
time specifies when the client is expected to be able to achieve the outcome. The
other options given (the client or part of the client; observable and measurable terms;
the action the patient will perform) are all part of client-centered measurable
outcomes.
35.
While developing the plan of care for a new client on the unit the nurse must identify expected
outcomes that are
appropriate for the new client. What is a resource for identifying these appropriate outcomes?
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A)
Community Specific Outcomes Classification (CSO)
B)
The Nursing-Sensitive Outcomes Classification (NOC)
C)
State Specific Nursing Outcomes Classification (SSNOC)
D)
Department of Health and Human Resources Outcomes Classification (HHROC)
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Ans: B
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Resources for identifying appropriate expected outcomes include the NursingSensitive Outcomes Classification (NOC) (Chart 3-6) and standard outcome criteria
established by health care agencies for people with specific health problems. The
other options are incorrect because they do not exist.
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Chapter 18, Implementing
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1.
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A client being prepared for discharge to his home will require several interventions in
the home environment. The nurse informs the discharge planning team, consisting of
a home health care nurse, physical therapist, and speech therapist, of
the client’s discharge needs. This interaction is an example of which professional nursing
relationship?
Nurse-health care team
B)
Nurse-patient
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C)
Nurse-patient-family
D)
Nurse-nurse
Ans: A
Feedback:
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A nurse-health care team professional relationship occurs when the nurse coordinates
the input of the multidisciplinary team into a comprehensive plan of care. The nurse
may also serve as a liaison between the client and family and the health care team, as
necessary.
A)
Research findings
B)
Resources
C)
Current standards of care
D)
Ethical and legal guides to practice
Ans: A
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2.
A graduate nurse recently attended a conference on acute coronary syndrome. In
preparing a plan of care for a client admitted with acute coronary syndrome, the nurse
considers the information she learned at the conference. Which
nursing variable is the nurse utilizing in the development of the plan of care?
Feedback:
Nurses concerned about improving the quality of nursing care use research findings
to enhance their nursing practice. Reading professional journals and attending
continuing education workshops and conferences are excellent ways to learn about
new nursing strategies that have proved effective.
3.
The American Nurses Association recommends adherence to defined principles when
delegating care tasks to unlicensed
assistive personnel. According to these principles, who is responsible and accountable for
nursing practice?
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A)
The registered nurse
B)
The American Nurses Association
C)
The nurse manager
D)
The unit’s medical director
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Ans: A
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It is the registered nurse who is responsible and accountable for nursing practice.
A)
Facilitate communication between the different professionals and attempt to coordinate care.
B)
Educate the client about the unique scope and focus of each member of the healthvcare team.
C)
Modify the client’s plan of care to better reflect the commonalities between the different
disciplines.
D)
Arrange for each professional to perform bedside assessments and interventions
simultaneously rather than individually.
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4.
An older adult client is receiving care on a rehabilitative medicine unit during her
recovery from a stroke. She complains that the physical therapist, occupational
therapist, neurologist, primary care physician, and speech language pathologist “don’t
seem to be on the same page” and that “everyone has their own plan for me.” How
can the nurse best respond to
the client’s frustration?
Ans: A
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Feedback:
Nurses play a pivotal role in the coordination of care and often need to facilitate
communication between members of different disciplines. Educating the client about
the role of each professional may be useful, but it does not achieve coordination of
care. Similarly, amending the client’s plan of care will not create unity and
collaboration. It is unrealistic to expect each member of the care team to always visit
simultaneously.
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A male client 30 years of age is postoperative day 2 following a nephrectomy (kidney
removal) but has not yet
5.
mobilized or dangled at the bedside. Which of the following is the nurse’s best
intervention in this client’s care?
Educate the client about the benefits of early mobilization and offer to assist him.
B)
Respect the client’s wishes to remain in his bed and ask him when he would like to begin
mobilizing.
C)
Show the client the expected outcomes on his clinical pathway that relate to mobilization.
D)
Document the client’s noncompliance and reiterate the consequences of delaying mobilization.
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A)
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Ans: A
Educating the client about the benefits of mobilizing, and offering to assist
combines teaching with the promotion of self-care. It is likely premature to label
the client as noncompliant, and showing him the expected outcomes on his
clinical pathway is unlikely to motivate him if he is reluctant. It is appropriate for the
nurse to educate and encourage the client rather than simply accepting his refusal and
providing no other interventions.
6.
Many of the homeless clients who are supposed to receive care for HIV/AIDS miss
their appointments at a clinic because it is located in a high-rise building on a
university campus. Several of the clients state that the clinic is difficult to find and in
an intimidating environment. This demonstrates that which of the following variables
influencing outcome
achievement is being inadequately addressed?
A)
Psychosocial background of clients
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Feedback:
B)
Developmental stage of clients
C)
Ethical and legal considerations
D)
Resources
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Ans: A
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Requiring clients to attend a clinic that is difficult to access, and located in a daunting
environment, shows a lack of consideration for clients’ psychosocial backgrounds.
Resources, development, and ethics are not central to this lapse in care.
A)
Environment
B)
Personnel
C)
Equipment
D)
Patient and
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7.
A female client 89 years of age has been admitted to the hospital with a diagnosis of
failure to thrive. She has become constipated in recent days, in spite of maintaining a
high fluid intake and taking oral stool softeners. She admits to her nurse that the
problem is rooted in the fact that she feels mortified to attempt a bowel movement on
a commode at her bedside where staff and other clients can hear her. The nurse should
respond by modifying which of the following
resources?
visitors Ans: A
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Feedback:
Providing an environment for the client that is more conducive to privacy and,
ultimately, to her elimination needs is necessary in this case. The equipment itself
(i.e., the commode) is not the problem, but rather its proximity to others. The staff and
the client herself are not central to the client’s new problem.
What is the unique focus of nursing implementation?
A)
Client response to health and illness
B)
Client response to nursing diagnosis
C)
Client compliance with treatment regimen
D)
Client interview and physical assessment
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8.
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Ans: A
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In all nurse–client interactions, the nurse is concerned with the client’s response to
health and illness and the nurse’s ability to meet basic human needs. Whereas other
health care professionals focus on selected aspects of the client’s treatment regimen,
nurses are concerned with how the client is responding to the plan of care in general.
9.
The researchers developing classifications for interventions are also committed to developing
a classification of which
of the following?
A)
Diagnoses
B)
Outcomes
C)
Goals
D)
Data clusters
Ans: B
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Feedback:
The researchers involved in the development of NICs are also committed to
developing a classification of client outcomes for nursing interventions, called
Nursing Outcomes Classifications (NOCs). This research aims to identify, label,
validate, and classify nursing-sensitive client outcomes and indicators, evaluate the
validity and usefulness of the classification in clinical field-testing, and define and
test measurement procedures for the outcomes and indicators.
What activity is carried out during the implementing step of the nursing process?
A)
Assessments are made to identify human responses to health problems.
B)
Mutual goals are established and desired client outcomes are determined.
C)
Planned nursing actions (interventions) are carried out.
D)
Desired outcomes are evaluated and, if necessary, the plan is modified.
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10.
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Ans: C
During the implementing step of the nursing process, nursing actions (interventions)
planned during the planning step are carried out.
11.
What role of the nurse is crucial to the prevention of fragmentation of care?
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A)
Advocate
B)
Educator
C)
Counselor
D)
Coordinator
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Ans: C
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One of nursing’s major contributions to the health care team is the role of
coordinator. Care can easily become fragmented when clients are seen by numerous
specialists—each interested in a different aspect of the client. It is important for the
nurse to make rounds with other health care professionals and to read the results of
consultations that clients have had with specialists. They can then interpret the
specialists’ findings for clients and family members, prepare clients to participate
maximally in the plan of care before and after discharge, and serve as a liaison
among the members of the health care team.
A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What
does this mean?
A)
The nurse is using critical thinking to implement the dressing change.
B)
The client has specified how the dressing should be changed.
C)
Written plans are developed that specify nursing activities for this skill.
D)
The physician verbally requested specific steps of the dressing change.
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Ans: C
Feedback:
Protocols (written plans that detail the nursing activities to be executed in specific
situations) are nurse-initiated interventions. They expand the scope of nursing
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practice in certain clearly defined situations.
A)
To implement evidence-based practice
B)
To ensure the order follows hospital policy
C)
To be sure interventions are individualized
D)
To be sure the intervention is safe
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13.
A client who was previously awake and alert suddenly becomes unconscious. The nursing
plan of care includes an order
to increase oral intake. Why would the nurse review the plan of care?
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Nurses reassess the client and review the plan of care before initiating any nursing
intervention. This is done to make sure that the plan of care is still responsive to the
client’s needs, and is safe for the particular client. In this case, the nurse would not
give oral fluids to an unconscious client.
A)
Ask the visitors to leave the room.
B)
Ask the client if visitors should remain in the room.
C)
Tell the client to ask the visitors to leave the room.
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14.
A nurse is preparing to insert an intravenous line and begin administering intravenous fluids.
The client has visitors in
the room. What should the nurse do?
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D)
Wait until the visitors leave to begin the procedure.
Ans: B
Feedback:
If visitors are in the client’s room, check with the client to see whether she or he
wants the visitors to stay during the procedure.
A)
Take the client’s vital signs after ambulation.
B)
Ask the client’s wife to assist with ambulation.
C)
Delay ambulation until the following shift.
D)
Ask another student to help with ambulation.
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15.
A student is ambulating a client for the first time after surgery. What would the student do to
anticipate and plan for an
unexpected outcome?
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Ans: D
Unexpected outcomes do occur, such as the risk of a fall for the postoperative client
who is ambulated for the first time. In anticipation, the student caregiver could ask
another student to help ambulate the client, thus decreasing this risk.
16.
The staff in a long-term care facility often plays loud rock music on the radio and designs
children’s games as exercise.
What is the staff doing in this situation?
A)
Considering the hearing level of older adults
B)
Failing to consider visual deficits that occur with aging
C)
Ignoring the developmental needs of older adults
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D)
Meeting needs for sensory input and exercise
Ans: C
Feedback:
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Nurses must be careful not to let stereotypes about developmental stages and tasks
influence client care. Playing loud rock music and designing children’s games ignore
the older adults’ needs and is demeaning.
A)
Nothing, the nurse’s honesty will not be questioned.
B)
The nurse can add the documentation after the client goes home.
C)
The physician will verify that the nurse carried out the order.
D)
In the eyes of the law, if it is not documented, it was not done.
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17.
A nurse administers a medication for pain but forgets to document it in the client’s medical
record. Legally, what does
this mean?
Feedback:
Nurses must carefully document each intervention. The legal truth is “if it wasn’t documented,
it wasn’t done.”
18.
A nurse delegates a specific intervention to a UAP. What implications does this have for the
nurse?
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A)
The UAP is responsible and accountable for his or her own actions.
B)
Nurses do not have authority to delegate interventions.
C)
The nurse transfers responsibility but is accountable for the outcome.
D)
The UAP can function in an independent role for all interventions.
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UAPs are trained to function in an assistive role to the RN in client activities as
delegated and supervised by the RN. Delegation is the transfer of responsibility of an
activity to another individual while retaining accountability for the outcome.
A)
Sitting with the client to encourage her to talk
B)
Telling the laboratory technician to speed up the results
C)
Calling the physician for an order for an anxiolytic
D)
Educating the client about reducing risk factors
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19.
A nurse on duty finds that a client is anxious about the results of laboratory testing. Which
intervention by the nurse
reflects a supportive intervention?
Ans: A
Feedback:
Supportive interventions include recognizing the need for encouragement,
unconditional acceptance of behaviors, and the positive effects of being present for
clients during stress or crisis. To support the anxious client, the nurse should sit with
her and encourage her to talk. Telling the laboratory technician to speed up the
results, or calling the physician and taking orders for anxiolytics are inappropriate
supportive interventions. Educating the client about reducing risk factors is an
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educational intervention.
Educating clients on their diabetic regimen of administering insulin is the implementation of
which skill?
A)
Intrinsic
B)
Technical
C)
Interpersonal
D)
Visual
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The administration of insulin is a technical skill. Technical competence means being
able to use equipment, machines, and supplies in a particular specialty.
A)
Ensure that UAPs closely follow the nursing process when providing care.
B)
Audit the client documentation that UAPs record after they perform interventions.
C)
Take frequent mini-reports from UAPs to ensure changes in client status are identified.
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21.
A registered nurse who provides care in a subacute setting is responsible for
overseeing and delegating to unlicensed assistive personnel (UAP). Which of the
following principles should the nurse follow when delegating to UAP? Select
all that apply.
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D)
Know what clinical cues the UAP should be alert for and why.
E)
Make frequent walking rounds to assess clients.
Ans: C, D, E
Feedback:
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The nurse must take careful action to ensure that delegation results in safe and
competent client care. This necessitates such measures as taking frequent minireports, identifying the clinical cues that UAPs should be aware of, and performing
rounds often. UAPs are not normally educated to follow the nursing process nor to
perform documentation.
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22.
Which of the following statements accurately describes a recommended guideline for
implementation? Select all that
apply.
When implementing nursing care, remember to act independently, regardless of the wishes of
the client/family.
B)
Before implementing any nursing action, reassess the client to determine whether the action is
still needed.
C)
Assume that the nursing intervention selected is the best of all possible alternatives.
D)
Consult colleagues and the nursing and related literature to see if other approaches might be
more successful.
E)
Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of
success.
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A)
Ans: B, D
Feedback:
When implementing nursing care, the nurse should act in partnership with the
client/family and reassess the client to determine if the nursing action is still needed.
The nurse should always question that the nursing intervention selected is the best of
all possible alternatives. The nurse should consult colleagues and related nursing
literature to see if other approaches might be more successful. The nurse should
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D)
Know what clinical cues the UAP should be alert for and why.
develop a repertoire of skilled nursing interventions, and check to make sure that the
ones selected are consistent with standards of care and within legal/ethical guidelines
to practice.
Which example reflects client variables that influence outcome achievement? Select all that
apply.
A)
The client was born with cystic fibrosis.
B)
The nurse works at a hospital in a diverse community.
C)
Nursing interventions are consistent with standards of care.
D)
The client is a college graduate and is employed.
E)
The client engages in activities associated with Ramadan.
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Important client variables that influence outcome achievement include the physical
health of the client, level of education attained, and cultural practices that impact life
and health practices. Nurse variables, such as working in a diverse community, and
standards of practice also influence client outcome achievement.
24.
The nurse is trying to determine factors influencing a client who is not following the plan of
care. Which client
statement identifies a potential factor interfering with following the plan of care? Select all
that apply.
A)
I don’t drive so I was unable to fill my prescription.
B)
I consult the list of low sodium foods when preparing meals.
C)
My social security check does not come until next week.
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D)
I dropped the strips for my finger-stick blood glucose testing in the bath water.
E)
“My daughter helps me with my range of motion exercises every morning and afternoon.”
Ans: A, C, D
Feedback:
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Common factors that contribute to a client not following the plan of care include
inability to afford treatment (social security check) and limited access to treatment
(doesn’t drive; damaged testing strips).
A)
Explain to the daughter the wishes of the client.
B)
Arrange a meeting between the physician and daughter.
C)
Contact the imaging center to schedule the testing.
D)
Persuade the client to agree to the daughter’s request.
Ans: A
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25.
The nurse is caring for a client with a diagnosis of end-stage renal disease. The client
has expressed the desire to be kept comfortable and to not continue further treatment.
The daughter arrives from out of town and is demanding to have further testing done
to determine the best treatment option for the client. What is the best action for the
nurse to take at
this time?
Feedback:
The priority is for the nurse to explain to the daughter the wishes of the client and
support the client’s decision. As an advocate, the nurse implements actions to protect
the rights of the client. The other options do not support the client’s decision.
26.
Which is a responsibility of the nurse in the nurse-client-family team relationship?
A)
Provide creative leadership to make the nursing unit a satisfying and challenging place to
work.
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D)
I dropped the strips for my finger-stick blood glucose testing in the bath water.
B)
Support the nursing care given by other nursing and non-nursing personnel.
C)
Educate the family to be informed and assertive consumers of health care.
D)
Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.
Ans: C
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Educating the family to be informed and assertive consumers of health care is a role
responsibility in the nurse-client- family relationship. Responsibilities of the nurse in
the nurse-health care team relationship include coordinating the inputs of the
multidisciplinary team into a comprehensive plan of care. In the nurse-nurse
relationship, the nurse provides creative leadership to make the nursing unit a
satisfying and challenging place to work, and supports the nursing care given by
other nursing personnel.
A)
Nurse-client
B)
Nurse-nurse
C)
Nurse-client-family
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27.
The nurse is caring for a client with a diagnosis of colon disease. The client has
expressed to various members of the health care team the desire to be kept
comfortable and to not continue further treatment. The client asks the nurse to be
present when the client discusses the decision with other family members. In which
professional nursing relationship is
the nurse participating?
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D)
Nurse-health care team
Ans: C
Feedback:
The nurse is fulfilling role responsibilities of the nurse-client-family relationship
when being present for a discussion of the matter by the client and family.
The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best
instruction by the nurse?
A)
Notify me right away if the client’s systolic blood pressure is 170 or greater.
B)
Let me know if the client’s blood pressure becomes elevated.
C)
If the client’s blood pressure falls outside normal limits, come get me.
D)
I need to know if the client’s blood pressure changes from his normal baseline.
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Ans: A
When delegating tasks, it is essential for the nurse to give clear instructions to the
person to whom the task is being delegated. The statement, which includes specific
parameters for the systolic blood pressure, clearly identifies what the UAP should be
alerted to and the subsequent action to take. The other three options are vague and do
not provide adequate direction for the UAP.
29.
The nursing student is caring for a Native American client who is admitted for deep
vein thrombosis. The nursing student speaks with a nurse regarding the client’s lack
of eye contact with the student. The nurse responds that Native
Americans view eye contact as an invasion of privacy. Which error did the nursing student
make?
A)
Failure to act in partnership with the client.
B)
Failure to approach the client caringly.
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C)
Failure to seek the client’s input in the plan of care.
D)
Failure to provide culturally sensitive care.
Ans: D
Feedback:
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The nursing student failed to provide culturally sensitive care by expecting the client
to engage in eye contact. There is no information to suggest the nursing student failed
to act in partnership with the client, approach the client caringly, or seek the client’s
input in the plan of care.
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The nurse is preparing to implement plans of care with several clients. Which action would be
inappropriate for the
nurse to perform?
Ask the English-as-a-Second-Language (ESOL) client to state in his or her own words what it
means to be NPO.
B)
Seek input from the family of how the client with aphasia normally communicates at home.
C)
Respond to the postoperative client’s question that baths are given only in the morning.
D)
Request that family members provide ethnic/cultural foods of the African client’s liking.
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A)
Ans: C
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Guidelines for implementing indicate that the nurse implements care that is
culturally sensitive and individualized for the client. The nurse forms a partnership
with the client and family when implementing care. The response by the nurse
indicating a set time for baths is not reflective of being open to individualizing client
care. The other options are consistent with the guidelines for implementing.
A)
Time management, communication, and establishing a support system.
B)
Establishing a support system, a sense of humor, and self-awareness.
C)
Self-awareness, preparation for crisis, and stress management.
D)
A sense of humor, anticipation of loss, and developing negative body image.
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31.
Nursing students need to learn to nurse themselves in order to prepare to be professional
nurses. Which activities would
fail to prepare nursing students for the delivery of nursing care?
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Activities that would prepare nursing students for the delivery of nursing care include
time management, communication, establishing a support system, self-awareness,
stress management, a sense of humor, and preparation for crisis and loss. Negative
body image is not desired.
32.
The nurse is assessing a client with a diagnosis of hypertension. The client’s blood
pressure is 178/88, an increase from 134/78 at the previous clinic visit. The nurse
asks the client what has changed from the previous visit. Which client
statement identifies a potential factor interfering with the plan of care?
A)
My husband has been ill and I don’t have anyone to help me care for him.
B)
I have learned to prepare foods differently so they are low in fat.
C)
My neighbor walks with me around the neighborhood every morning.
D)
I have been taking my hydrochlorothiazide (HydroDIURIL) every day.
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Ans: A
Feedback:
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Common factors that contribute to a client not following the plan of care include lack
of family support, inability to afford treatment, limited access to treatment, and
adverse physical or emotional effects of treatment. The burden of caring for her
husband may be placing stress on the client, and causing her blood pressure to be
elevated despite engaging in health promotion and blood pressure-lowering
activities.
A)
Nursing interventions must be consistent with standards of care and research findings.
B)
Nursing interventions must be culturally sensitive and individualized for the client.
C)
Nursing interventions must be compatible with other therapies planned for the client.
D)
Nursing interventions must be approved by other members of the health care team.
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33.
The nurse overhears two nursing students talking about nursing interventions. Which
statement by one of the nursing
students indicates further education is required?
Feedback:
Nursing interventions should be based on the etiology in the nursing diagnosis, be
compatible with other planned therapies, be consistent with standards of care and
research, and individualized for the client. Nursing interventions can
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be independent, dependent, and interdependent. Independent nursing interventions are
nurse-initiated interventions directed at the etiology of the client problem; they do not
require approval from other members of the health care team.
B)
Dependence
C)
Competence
D)
Discipline
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34.
Each time a nurse administers an insulin injection to a client with diabetes, she tells the client
what she is doing and
demonstrates each step of preparing and giving the injection. What is the nurse promoting in
the client?
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The plan of nursing care should include specific instructions for education/learning
needs of the client to promote self- care and independence. Competency pertains to
the nurse’s ability (knowledge, skills, and attitudes) to provide safe and effective care.
The nurse’s role includes education, counseling, and advocating, but not providing
discipline to clients.
35.
What characteristic of a competent nurse practitioner enables nurses to be role models for
clients?
A)
Sense of humor
B)
Writing ability
C)
Organizational skills
D)
Good personal health
Ans: D
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Feedback:
Good personal health enables nurses not only to practice more efficiently, but also to
be a health model for clients and their families. Nurses can help clients to imitate
good health behaviors, and eventually integrate them into their daily life through the
process of identification.
Chapter 19, Evaluating
A)
Terminate the plan of care.
B)
Modify the plan of care.
C)
Continue the plan of care.
D)
Re-evaluate the plan of care.
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1.
Upon evaluation of the client’s plan of care, the nurse determines that the expected outcomes
have been achieved. Based
upon this response, the nurse will do what?
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Ans: A
The nurse will terminate the plan of care when each expected outcome has been
achieved. Modifying the plan of care is necessary if there are difficulties in achieving
the outcomes. Re-evaluating each step of the nursing process is a step in the
modification of a plan of care. Continuing the plan of care occurs if more time is
needed to achieve the outcomes.
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Nursing care and client outcomes may be evaluated by use of a retrospective evaluation process. Which of the following
is an example of a retrospective evaluation process?
A)
Postdischarge questionnaire.
B)
Direct observation of nursing care.
C)
Client interview during hospitalization.
D)
Review of client’s chart during hospitalization.
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Retrospective evaluation may use postdischarge questionnaires and client interviews,
or chart reviews after the client has been discharged. Concurrent evaluation occurs
while the client is receiving care and may include the following: direct observation of
nursing care and client interviews; and direct observation of chart reviews during
hospitalization.
A)
Continue the plan of care with the aim of helping the client achieve the outcomes.
B)
Terminate the plan of care since it does not accurately reflect the client’s abilities.
C)
Modify the plan of care to better reflect the client’s current functional ability.
D)
Replace the client’s individualized plan of care with a clinical pathway.
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3.
An older adult client has lost significant muscle mass during her recovery from a
systemic infection. As a result, she has not yet met the outcomes for mobility and
activities of daily living that are specified in her nursing plan of care. How
should her nurses best respond to this situation?
Ans: A
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Nursing care and client outcomes may be evaluated by use of a retrospective evaluation process. Which of the following
Nurses regularly evaluate clients’ progression toward the achievement of outcomes
that are specified in plans of care. When clients need more time to achieve desired
outcomes, it is appropriate to continue with the existing plan of care. It is not
necessary to terminate the plan of care and modification may be premature.
Abandoning the plan and replacing it with a clinical pathway is counterproductive to
the continuity of care.
A)
Information
B)
Science
C)
Cooperation
D)
Individualization
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4.
The nurse has responded to a client’s request to view her medical chart by arranging a
meeting between the client, the clinical nurse leader, and her primary care physician.
The nurse is exemplifying which of the following characteristics of
quality health care?
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The Institute of Medicine’s Committee on Quality Health Care in America has
identified aspects of care that clients can reasonably expect. One of these expectations
is information, which is manifested by allowing clients access to their medical
records. Other characteristics that clients can expect are knowledge-based care
(science), coordination between professionals (cooperation), and respect for client
choices and preferences (individualization).
5.
Nurses have identified the following outcome in the care of a client who is recovering from a
stroke: “Client will
ambulate 100 feet without the use of mobility aids by 12/12/2011.” Several nurses have
evaluated the client’s
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progression towards this outcome at various points during her care. Which of the
following evaluative statements is most appropriate?
“12/12/2011 – Outcome partially met. Patient ambulated 75 feet without the use of mobility
aids”
B)
“12/12/2011 – Outcome unmet. Patient’s ambulation remains inadequate.”
C)
“12/10/2011 Outcome met, but with the use of a quad cane to assist ambulation.”
D)
“12/14/2011 Outcome met.”
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An evaluative statement should include both the decision about how well the outcome
was met along with data that support this decision. Characterizing the client’s
ambulation as “inadequate” is not sufficiently precise. Stating that this outcome was
met with the use of a cane contradicts the original terms of the outcome.
A)
Report the nurse’s practice and have the nurse manager address the matter.
B)
Encourage the nurse to attend an in-service on IV starts.
C)
Reassure the nurse that this is a difficult skill and give her feedback on her performance.
D)
Document an unmet outcome in the client’s plan of care.
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6.
The nurse witnessed a more senior nurse make six unsuccessful attempts at starting
an intravenous (IV) line on a client. The senior nurse persisted, stating, “I refuse to
admit defeat.” This resulted in unnecessary pain for the client. How
should the first nurse best respond to this colleague’s incompetent practice?
Ans: A
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According to the study Silence Kills: The Seven Crucial Conversations for
Healthcare (Maxfield, Grenny, Patterson, McMillan, & Switzler, 2005), an
appropriate response to incompetence is to report the matter and enlist the manager to
conduct follow-up. Reassuring the nurse and encouraging education are not sufficient
responses to incompetence. This action does not constitute an unmet outcome on the
part of the client.
A)
Use them to inform improvements and education on the unit.
B)
Use them to identify deficient workers for removal or demotion.
C)
Cross-reference them with client satisfaction reports from the unit.
D)
Use them to identify individuals who would benefit from probationary measures.
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7.
The manager of a medical unit regularly reviews the incident reports that result from errors
and near misses that occur
on the unit. How should the manager best respond to these incident reports?
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It is most beneficial for the manager to frame incident reports as sources of
improvement, which can improve both client care and the work environment.
Punitive follow-up by demotion, probation, or removal is likely to create reluctance
among staff to complete incident reports. Cross-referencing incident reports with
client satisfaction reports is unlikely to result in substantial improvements to the
unit’s care and culture.
8.
What cognitive processes must the nurse use to measure client achievement of outcomes
during evaluation?
A)
Intuitive thinking
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B)
Critical thinking
C)
Traditional knowing
D)
Rote memory
Ans: B
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Each element of evaluation requires the nurse to use critical thinking about how best
to evaluate the client’s progress toward valued outcomes.
A)
Psychomotor
B)
Affective
C)
Physiologic
D)
Cognitive
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9.
A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie
content of foods. What
type of outcome is this?
Feedback:
Cognitive goals involve increasing client knowledge. These goals may be evaluated
by asking clients to repeat information or to apply new knowledge in their everyday
lives.
10.
A nurse is educating a client on how to administer insulin, with the expected outcome that the
client will be able to selfadminister the insulin injection. How would this outcome be evaluated?
A)
Asking the client to verbally repeat the steps of the injection
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B)
Asking the client to demonstrate self-injection of insulin
C)
Asking family members how much trouble the client is having with injections
D)
Asking the client how comfortable he or she is with injections
Ans: B
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Psychomotor outcomes describe the client’s achievement of new skills and are
evaluated by asking the client to demonstrate the new skill.
A)
Outcome met
B)
Outcome partially met
C)
Outcome not met
D)
Outcome
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11.
A nurse in a community health center has been having regular meetings with a
woman who wants to stop smoking. Which of the following outcome decision
options would the nurse document if the woman has not smoked for three
months?
inappropriate Ans:
A
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Feedback:
After data have been collected and interpreted to determine client outcome
achievement, the nurse makes and documents a judgment summarizing the findings.
The three decision options are met, partially met, and not met. In this case, the
nurse’s judgment is that the client has met the expected outcome of smoking
cessation.
A)
Discover the problem.
B)
Plan a strategy.
C)
Implement a change.
D)
Assess the change.
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12.
A nurse is interested in improving client care on the unit through performance improvement.
What is the first step in this
process?
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Each nurse must decide how to respond when he or she perceives that client care is
being compromised. The four steps listed are all components of the process of
performance improvement, with discovering the problem being the first step.
13.
A nurse forgets to raise the bed railings of a client who is confused after taking pain
medications. The client attempts to get out of bed, and suffers a minor fall. The nurse
asks a colleague who witnessed the fall not to mention it to anyone
because the client only had minor bruises. What would be the appropriate action of the
colleague?
A)
No other steps need to be taken, since the client was not seriously injured.
B)
The colleague should inform the nurse that a full report of the incident needs to be made.
C)
The colleague should monitor the client closely for any adverse effects of the fall.
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D)
The colleague should report the incident in a peer review of the nurse.
Ans: B
Feedback:
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The colleague should tell the nurse that a full report needs to be made. If appropriate,
the colleague could help the nurse identify what contributed to her not raising the bed
railings in an effort to prevent it from happening in the future.
A)
Discuss any lack of progress with the client.
B)
Collect information on abnormal functions.
C)
Identify the client’s health-related problems.
D)
Select appropriate nursing interventions.
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14.
A nurse is evaluating and revising a plan of care for a client with cardiac catheterization.
Which of the following actions
should the nurse perform before revising a plan of care?
Feedback:
The nurse should discuss any lack of progress with the client so that both the client
and the nurse can speculate on what activities need to be discontinued, added, or
changed. Collecting information on abnormal functions and risk factors is done
during the assessment. Identification of the client’s health-related problems is done
during diagnosis. Nurses select appropriate nursing interventions and document the
plan of care in the planning stage of the nursing process, not during evaluation.
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A)
process evaluation
B)
structure evaluation
C)
outcome evaluation
D)
summary evaluation
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15.
When a charge nurse evaluates the need for additional staff nurses and additional monitoring
equipment to meet the
client’s needs, the charge nurse is performing an evaluation termed …
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Structure evaluation focuses on the attributes of the setting or surroundings where health care
is provided.
A)
Outcome evaluation
B)
Summary evaluation
C)
Structure evaluation
D)
Process evaluation
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16.
When a nursing supervisor evaluates the staff nurse’s performance with a group of clients to
whom the staff nurse has
provided nursing care, the supervisor is performing which type of evaluation?
Ans: D
Feedback:
Process evaluation focuses on the nurse’s performance and whether the nursing care
provided was appropriate and competent.
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A)
Base care on continuous healing relationships.
B)
Customize care based on available resources.
C)
Keep the nurse as the source of control.
D)
Share knowledge and allow for free flow of information.
E)
Practice evidence-based decision making.
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17.
A nurse working in a hospital setting discovers problems with the delivery of
nursing care on the pediatric unit.Which of the following suggestions from the
Institute of Medicine’s Committee on Quality of Health Care in America(Kohn,
Corrigan, & Donaldson, 2000) could help redesign and improve care? Select all that apply.
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The Institute of Medicine’s Committee on Quality of Health Care in America (Kohn,
Corrigan, & Donaldson, 2000) suggests 10 new rules to redesign and improve care:
(1) care based on continuous healing relationships, (2) customization based on client
needs and values, (3) the client as the source of control, (4) shared knowledge and the
free flow of information, (5) evidence-based decision making, (6) safety as a system
property, (7) the need for transparency,
(8) anticipation of needs, (9) continuous decrease in waste, and (10) cooperation among
clinicians.
18.
A nurse is counseling a novice nurse who gives 150% effort at all times and is
becoming frustrated with a health care system that provides substandard care to
clients. Which of the following advice would be appropriate in this situation?
Select all that apply.
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Tell the new nurse to help other nurses perform their jobs, thus ensuring quality client care is
being delivered.
B)
Encourage the new nurse to leave her problems at work behind, instead of rehashing them at
home.
C)
After establishing a reputation for delivering quality nursing care, have her seek creative
solutions for nursing problems.
D)
Tell her to view nursing care concerns as challenges rather than overwhelming obstacles, and
seek help for solutions.
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E)
State that if resources do not permit quality care, it is not the role of the new nurse to explore
change strategies within
the institution.
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The following items are good advice for nurses experiencing burnout: Learn to give
quality care during designated work period; leave on time; avoid the temptation to do
the work of others; and leave work concerns at work. After establishing a reputation
for delivering quality nursing care, seek creative solutions for nursing problems
(strategies to increase nursing resources, motivation, morale) and try them —
hopefully with a support network. View concerns as challenges rather than
overwhelming obstacles. Develop a realistic sense of how much nursing care (and of
what quality) can be delivered with existing resources. If resources do not permit
quality care, explore change strategies within the institution. If administration is not
supportive, explore other practice settings.
19.
Which activity does the nurse perform during the evaluating stage? Select all that apply.
A)
Validates with the client the problem of constipation.
B)
Collects data to determine the number of catheter-associated infections on the nursing unit.
C)
Increases the frequency of repositioning from every two hours to every one hour.
D)
Sets a goal of ambulating from bed to room door and back to bed.
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E)
Identifies smoking and sedentary lifestyle as risk factors for hypertension.
Ans: B, C
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During the evaluation stage, the nurse modifies the plan of care if desired outcomes
are not achieved (increased frequency of repositioning) and collects data, such as
number of infections, to monitor quality and effectiveness of nursing practice. During
the diagnosis stage, the nurse identifies factors contributing to the client’s health
problem, such as smoking and sedentary lifestyle, and validates the identified health
problems (such as constipation) with the clients. The nurse establishes plan priorities
and sets goals with the client and family during the outcome identification and
planning.
Which activity does the nurse engage in during evaluation? Select all that apply.
A)
Collect data to determine whether desired outcomes are met.
B)
Assess the effectiveness of planned strategies.
C)
Adjust the time frame to achieve the desired outcomes.
D)
Involve the client and family in formulating desired outcomes.
E)
Initiate activities to achieve the desired outcomes.
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20.
Ans: A, B, C
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The nurse establishes desired outcomes with the client and family during the outcome
identification and planning stage. The nurse initiates activities to achieve the desired
outcomes during the implementation stage. During the evaluation stage, the nurse
collects data to determine whether desired outcomes are met, assesses the
effectiveness of planned strategies, and adjusts the time frame to achieve the desired
outcomes.
Which client outcome is a physiologic outcome? Select all that apply.
A)
The client’s HA1c is 7.4%.
B)
The client’s blood pressure is 118/74.
C)
The client rates his or her pain rating as 6.
D)
The client self-administers insulin subcutaneously.
E)
The client describes manifestations of wound infection.
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Physiologic outcomes are physical changes in the client, such as pain ratings and
blood pressure and HA1c measurements. Psychomotor outcomes describe the
client’s achievement of new skills, such as insulin administration. Cognitive
outcomes demonstrate gains in client knowledge, such as manifestations of infection.
22.
Which activity is a possible solution for inadequate nursing staffing?
A)
Identify the kind and amount of nursing services required.
B)
Learn to give quality care during designated work period.
C)
Use a team conference to develop a consistent plan of care.
D)
Educate the client to become an assertive health care consumer.
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Ans: A
Feedback:
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A possible solution for inadequate staffing is to identify the kind and amount of
nursing services required. Using a team conference to develop a consistent plan of
care is a possible solution for the client who refused to cooperate with the therapeutic
regimen. Educating the client to become an assertive health care consumer is a
possible solution for the client who quietly accepts whatever care is delivered or not
delivered. A possible solution for the nurse who is a candidate for burnout is to learn
to give quality care during the designated work period.
A)
Assessment
B)
Outcome identification
C)
Implementation
D)
Evaluation
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23.
The nurse assesses urine output following administration of a diuretic. Which step of the
nursing process does this
nursing action reflect?
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Feedback:
Assessing the client’s response to a diuretic medication is an example of evaluation.
During assessment, the nurse collects and synthesizes data to identify patterns. The
nurse establishes desired outcomes with the client and family
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during the outcome identification and planning stage. The nurse initiates activities to
achieve the desired outcomes during the implementation stage.
A)
Design evaluation
B)
Process evaluation
C)
Outcome evaluation
D)
Structure evaluation
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24.
The nurse participates in a quality assurance program. Data from the previous year
indicates a 2% reduction in the number of repeat admissions for clients who
underwent hip replacement surgery. The nurse recognizes this is which type
of evaluation?
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Quality assurance programs focus on three types of evaluation: structure, process, and
outcome. Outcome evaluation focuses on measurable changes in the health status of
clients, such as a 2% reduction in the number of repeat admissions for clients who
underwent hip replacement surgery. Structure evaluation focuses on the environment
in which care is provided, whereas process evaluation focuses on the nature and
sequence of activities carried out by implementing the nursing process. There is no
design evaluation.
25.
The nurse participates in a quality assurance program and reviews evaluation data for the
previous month. Which of the
following does the nurse recognize as an example of process evaluation?
A)
A 10% reduction in the number of ventilator-associated pneumonia
B)
A 5% increase in the number of nosocomial catheter-related urinary tract infections
C)
40% of all client rooms in the facility are private and equipped with a computer
D)
A nursing care plan was developed within the eight hours of admission for 97% of all
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admissions.
Ans: D
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Process evaluation focuses on the nature and sequence of activities carried out by
nurses implementing the nursing process, such as the timing of nursing care plan
creation. Quality assurance programs focus on three types of evaluation: structure,
process, and outcome. Outcome evaluation focuses on measurable changes in the
health status of clients, such as the number of ventilator-associated pneumonia and
nosocomial catheter-related urinary tract infections. Structure evaluation focuses on
the environment in which care is provided, such as the number of private rooms
equipped with a computer.
A)
The client’s ability to reposition self in bed.
B)
Pressure-relieving mattress on the bed.
C)
Percent intake of a diet high in protein.
D)
Condition of the skin over bony prominences.
Ans: D
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26.
The client’s expected outcome is The client will maintain skin integrity by discharge. Which
of the following measures
is best in evaluating the outcome?
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During evaluation, the nurse collects data and makes a judgment summarizing the
findings. In making a decision about how well the outcome was met, the nurse
examines client data or behaviors that validate whether the outcome is met. The
condition of the skin, especially over bony prominences, provides the best measure
of whether skin integrity has been maintained.
A)
Goal partially met; client identified fever and presence of wound discharge.
B)
Client understands the signs and symptoms of infection.
C)
Goal partially met; client able to perform activities of daily living.
D)
Goal not met; white blood cell count elevated, presence of yellow-green discharge from
wound.
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27.
An expected client outcome is, The client will remain free of infection by discharge.
When evaluating the client’s progress, the nurse notes the client’s vital signs are
within normal limits, the white blood cell count is 12,000, and the client’s abdominal
wound has a half-inch gap at the lower end with yellow-green discharge. Which
statement would be
an appropriate evaluation statement?
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During evaluation, the nurse collects data and makes a judgment summarizing the
findings. In making a decision about how well the outcome was met, the nurse has
three options: met, partially met, or not met. An elevated white blood cell count and
the presence of yellow-green wound discharge are clinical manifestations consistent
with an infectious process, so the outcome has not been met.
28.
The nurse is caring for a client who is experiencing an asthma attack. Ten minutes
after administering an inhaled bronchodilator to the client, the nurse returns to ask if
the client’s breathing is easier. The nurse is engaging in which
phase of the nursing process?
A)
Assessment
B)
Diagnosing
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C)
Planning
D)
Implementing
E)
Evaluating
Ans: E
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The nurse is collecting evaluative data to determine whether or not the client is achieving the
therapeutic response to the bronchodilator.
A)
Retrospective evaluation
B)
Peer review
C)
Nursing audit
D)
Concurrent evaluation
Ans: A
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29.
The nurse is preparing to mail a client satisfaction questionnaire to a client who was
discharged from the hospital four
days ago. Which type of evaluation is the nurse conducting?
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A retrospective audit uses post-discharge questionnaires to collect data. A nursing
audit is a method of evaluating nursing care that involves reviewing client records to
assess the outcomes of nursing care (or the process by which these outcomes were
achieved). Concurrent evaluation involves direct observations of nursing care, client
interviews, and chart review to determine whether the specified evaluative criteria
are met. Peer review involves the evaluation of one staff member by another staff
member on the same level in the hierarchy of the organization. This is done for the
purpose of professional performance improvement.
A)
Client taking antibiotic as ordered.
B)
Client identifies signs and symptoms of recurrence of infection.
C)
Client coughing and deep breathing every one hour.
D)
Client no longer requires oxygen.
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30.
The nurse is caring for the client with pneumonia. An expected client outcome is, The client
will maintain adequate
oxygenation by discharge. Which outcome criterion indicates the goal is met?
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The client who is maintaining adequate oxygenation would not require oxygen. The
client could be able to do the other three options and still have problems with
oxygenation.
31.
The client reports participating in water aerobics for 60 minutes three times each week. This is
an example of what type
of outcome?
A)
Affective outcome
B)
Psychomotor outcome
C)
Physiologic outcome
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D)
Cognitive outcome
Ans: A
Feedback:
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An affective outcome involves changes in the client’s values, beliefs, and attitude,
such as participating in water aerobics. Cognitive outcomes demonstrate increases in
client knowledge. Physiologic outcomes are physical changes in the client.
Psychomotor outcomes describe the client’s achievement of new skills.
A)
Affective outcome
B)
Psychomotor outcome
C)
Physiologic outcome
D)
Cognitive outcome
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32.
The client’s pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal
cannula. This is an example
of what type of outcome?
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Feedback:
Physiologic outcomes are physical changes in the client, such as pulse oximetry. An
affective outcome involves changes in the client’s values, beliefs, and attitude.
Cognitive outcomes demonstrate increases in client knowledge. Psychomotor
outcomes describe the client’s achievement of new skills.
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A)
Appropriate staffing
B)
Effective decision making
C)
True collaboration
D)
Skilled communication
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33.
The nurse is giving a shift report to the oncoming nurse who will be caring for a
client with a portacath access device. The oncoming nurse states, I have never taken
care of a client with a portacath. Would you give me the basics, so I know what to
do? Which standard for establishing and sustaining healthy work environments is the
oncoming nurse
breaching?
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Appropriate staffing ensures that client needs are effectively matched with nurse
competencies. In this scenario, the nurse is ill-prepared to care for the client. The
nurse needs structured training to learn about the nursing care of portacaths. Skilled
communication requires health team members to communicate in a respectful, nonintimidating manner with colleagues. True collaboration involves skilled
communication, mutual respect, shared responsibility, and decision making among
nurses, and between nurses and other health team members. Effective decision
making ensures nurses are valued and active partners in making policy, directing and
evaluating clinical care, and leading organizational operations.
The correct sequence of steps for performance improvement is:
1.
Discover a problem.
2.
Plan a strategy using indicators.
3.
Implement a change.
34.
4. Assess the change.
A)
1, 2, 3, 4
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B)
1, 4, 2, 3
C)
4, 1, 2, 3
D)
1, 2, 4, 3
E)
1, 3, 2, 4
Ans: A
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The correct sequence of steps for performance improvement is (1) discover a
problem; (2) plan a strategy using indicators; (3) implement a change; and (4) assess
the change; if the change is not met, plan a new strategy.
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Chapter 20, Documenting & Reporting
A client’s diagnosis of pneumonia requires treatment with antibiotics. The corresponding
order in the client’s chart
1.
should be written as …
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A)
Avelox (moxifloxacin) 400 mg daily
B)
Avelox (moxifloxacin) 400 mg Q.D.
C)
Avelox (moxifloxacin) 400 mg qd
D)
Avelox (moxifloxacin) 400 mg OD
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Ans: A
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Among the JCAHO’s list of “do not use” abbreviations are Q.D., qd, and OD when
denoting a once-per-day drug administration. Because of the potential for
misinterpretation and consequent drug errors, the JCAHO recommends writing
“daily” in the order.
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2.
The nurses who provide care in a large, long-term care facility utilize charting by exception
(CBE) as the preferred
method of documentation. This documentation method may have which of the following
drawbacks?
Vulnerability to legal liability since nurse’s safe, routine care is not recorded
B)
Increased workload for nurses in order to complete necessary documentation
C)
Failure to identify and record client problems and associated interventions
D)
Significant differences in the charting between nurses due to lack of standardization
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A)
Ans: A
Feedback:
A significant drawback to charting by exception is its limited usefulness when trying
to prove high-quality safe care in response to a negligence claim made against
nursing. CBE is generally less time-consuming than alternate methods of
documentation, and both standardization of charting and identification of clientspecific problems are possible within this documentation framework.
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A)
Narrative notes
B)
SOAP notes
C)
Focus charting
D)
Charting by exception
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3.
The nurse managers of a home health care office wish to maximize nurses’ freedom
to characterize and record client conditions and situations in the nurses’ own terms.
Which of the following documentation formats is most likely to
promote this goal?
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One of the advantages of a narrative notes model of documentation is that it allows
nurses to describe clinical encounters in their own terms, as they understand them.
Other documentation formats, such as SOAP notes, focus charting, and charting by
exception, are more rigidly delineated and allow nurses less latitude in their
documentation.
A)
“Client complaining of abdominal pain rated at 8/10.”
B)
“Client is guarding her abdomen and occasionally moaning.”
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4.
A hospital utilizes the SOAP method of charting. Within this model, which of the nurse’s
following statements would
appear at the beginning of a charting entry?
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C)
“Client has a history of recent abdominal pain.”
D)
“2 mg Dilaudid PO administered with good effect”
Ans: A
Feedback:
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The SOAP method of charting (Subjective data, Objective data, Assessment, Plan)
begins with the information provided by the client, such as a complaint of pain. The
nurse’s objective observations and assessments follow, with interventions, actions, and
plans later in the charting entry.
What is the nurse’s best defense if a client alleges nursing negligence?
A)
Testimony of other nurses
B)
Testimony of expert witnesses
C)
Client’s record
D)
Client’s family
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5.
Feedback:
The client record is the only permanent legal document that details the nurse’s
interactions with the client. It is the best defense if a client or client surrogate alleges
nursing negligence.
6.
A nurse is documenting the intensity of a client’s pain. What would be the most accurate
entry?
A)
“Client complaining of severe pain.”
B)
“Client appears to be in a lot of pain and is crying.”
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C)
“Client states has pain; walking in hall with ease.”
D)
“Client states pain is a 9 on a scale of 1 to 10.”
Ans: D
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Information should be documented in a complete, accurate, relevant, and factual
manner. Avoid interpretations of behavior, generalizations, and words such as
“good.”
Which of the following data entries follows the recommended guidelines for documenting
data?
A)
“Client is overwhelmed by the diagnosis of pancreatic cancer.”
B)
“Client’s kidneys are producing sufficient amount of measured urine.”
C)
“Following oxygen administration, vital signs returned to baseline.”
D)
“Client complained about the quality of the nursing care provided on previous shift.”
Ans: C
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7.
Feedback:
The nurse should record client findings (observations of behavior) rather than an
interpretation of these findings, and avoid words such as “good,” “average,”
“normal,” or “sufficient,” which may mean different things to different readers.
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The nurse should also avoid generalizations such as “seems comfortable today.” The
nurse should avoid the use of stereotypes or derogatory terms when charting, and
should chart in a legally prudent manner.
Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How
should she sign the entry?
A)
Alice J, RN
B)
A. Jones, RN
C)
Alice Jones
D)
AJRN
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Each entry is signed with the first initial, last name, and title. In this case, A. Jones, RN, is
correct.
A)
Writing the client’s name on the student care plan
B)
Providing the instructor with plans for care
C)
Discussing the medications with a unit nurse
D)
Providing information to the physician about laboratory data
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9.
A student has reviewed a client’s chart before beginning assigned care. Which of the
following actions violates client
confidentiality?
Ans: A
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Students using client records are bound professionally and ethically to keep in strict
confidence all the information they learn from those records. The student may discuss
care with the instructor, medications with a staff nurse, and laboratory data with the
physician. The student should not use actual client names or other identifiers in
written assignments or oral reports.
A physician’s order reads “up ad lib.” What does this mean in terms of client activity?
A)
May walk twice a day
B)
May be up as desired
C)
May only go to the bathroom
D)
Must remain on bed rest
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The abbreviation “up ad lib” means the client may be up as desired.
In what type of documentation method would a nurse document narrative notes in a nursing
section?
A)
Problem-oriented medical record
B)
Source-oriented record
C)
PIE charting system
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D)
Focus charting
Ans: B
Feedback:
A source-oriented record is one in which each health care group keeps data on its own
separate form (e.g., physicians, nurses, and laboratory). Progress notes written by
nurses using this method are narrative notes.
A)
Problem-oriented medical record (POMR)
B)
Source-oriented record
C)
PIE charting system
D)
focus charting
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12.
Which one of the following methods of documentation is organized around client diagnoses
rather than around patient
information?
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Feedback:
The POMR is organized around a client’s problems rather than around sources of
information. With POMRs, all health care professionals record information on the
same forms. The advantages of this type of record are that the entire health care team
works together in identifying a master list of client problems and contributes
collaboratively to the plan of care.
13.
A nurse organizes client data using the SOAP format. Which of the following would be
recorded under “S” of this
acronym?
A)
Client complaints of pain
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B)
Client history
C)
Client’s chief complaint
D)
Client interventions
Ans: A
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The SOAP format (subjective data, objective data, Assessment [the caregiver’s
judgment about the situation], plan) is used to organize data entries in the progress
notes of the POMR. A client complaint of pain is subjective data (S).
A)
Problem-oriented medical record
B)
Charting by exception
C)
PIE charting system
D)
Focus charting
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14.
Which of the following methods of documenting client data is least likely to hold up in court if
a case of negligence is
brought against a nurse?
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Charting by exception is a shorthand documentation method that makes use of welldefined standards of practice; only significant findings or “exceptions” to these
standards are documented in narrative notes. A significant drawback to charting by
exception is its limited usefulness when trying to prove high-quality safe care in
response to a negligence claim made against nursing.
A nurse has access to computerized standardized plans of care. After printing one for a client,
what must be done next?
A)
Date it and put it in the client’s record.
B)
Sign it and put it in the Kardex.
C)
Individualize it to the specific client.
D)
Use it as printed, based on common needs.
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Standardized care plans that identify common problems and needs with relation to
select client cohorts may be used. Unless such care plans are individualized to a
specific client, however, they may not address individual client needs.
16.
What part of the client’s record is commonly used to document specific client variables, such
as vital signs?
A)
Progress notes
B)
Nursing notes
C)
Critical paths
D)
Graphic record
Ans: D
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Feedback:
The graphic record is a form used to document specific client variables such as vital
signs, weight, intake and output, and bowel movements.
17.
A nurse is documenting information about a client in a long-term care facility. What is used in
a Medicare-certified
facility as a comprehensive assessment and as the foundation for the Resident Assessment
Instrument (RAI)?
PIE system
B)
Minimum data set
C)
OASIS
D)
Charting by exception
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Long-term care documentation is specified by the RAI with the minimum data set
forming the foundation for the assessment. This is required in all facilities certified to
participate in Medicare or Medicaid. OASIS is used in the home health care industry.
18.
What is the primary purpose of an incident report?
A)
Means of identifying risks
B)
Basis for staff evaluation
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C)
Basis for disciplinary action
D)
Format for audiotaped report
Ans: A
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An incident report, also termed a variance or occurrence report, is a tool used by
health care agencies to document the occurrence of anything out of the ordinary that
results in, or has the potential to result in, harm to a client, employee, or visitor.
Incident reports should not be used for disciplinary action against staff members.
A group of nurses visits selected clients individually at the beginning of each shift. What are
these procedures called?
A)
Nursing care conferences
B)
Staff visits
C)
Interdisciplinary referrals
D)
Nursing care rounds
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19.
Feedback:
Nursing care rounds are procedures in which a group of nurses visits select clients
individually at each client’s bedside. The primary purposes are to gather information
to help plan and evaluate nursing care and to provide the client with an opportunity to
discuss care.
20.
A nurse uses informatics to plan nursing care for a client. Which three terms best describes
this science as it is applied to
nursing?
A)
Data, information, knowledge
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B)
Process, documentation, analysis
C)
Research, controls, variables
D)
Hypothesis, nursing, practice
Ans: A
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According to the ANA Scope and Standards of Nursing Informatics Practice, nursing
informatics is a specialty that integrates nursing science, computer science, and
information science to manage and communicate data, information, and knowledge
in nursing practice. Nursing informatics facilitates the integration of data,
information, and knowledge to support clients, nurses, and other providers in their
decision making in all roles and settings. This support is accomplished through the
use of information structures, information processes, and information technology
(ANA, 2001, p. vii).
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21.
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A client complains to the nurse-in-charge about another nurse on night shift. The
client says that he kept calling the nurse but she never responded. Further, when he
questioned the nurse, she said that she had other patients to take care
of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate
response for the nurse?
A)
“I am sorry that you had to suffer this way. The nurse on night duty should be fired.”
B)
“It’s hard to be in bed and ask for help. You ring for a nurse who never seems to help.”
C)
“You seem to be impatient. The nurses work very hard and they do whatever they can.”
D)
“I can see that you are angry. What the nurse did is wrong, and it won’t happen again.”
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Ans: B
Feedback:
The nurse should empathize with the client to perceive how the client is feeling. The
nurse shares his or her perception with the client, which makes him comfortable to
share his anxieties, fear, and concerns. The first response conveys pity on the client,
which is inappropriate. In the third response, the nurse is taking the side of the
nursing staff and the client may not like it. The fourth response is nontherapeutic.
A)
Pay courtesy calls to staff members before attending the meeting.
B)
Wait for the physicians to arrive before exchanging notes.
C)
Avoid asking questions related to the medical record.
D)
Come prepared with material required to take notes.
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22.
A nurse at a health care facility has just reported for duty. Which of the following should the
nurse do to ensure
maximum efficiency of change-of-shift reports?
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Ans: D
The nurse should come prepared with material required to take notes during the
change-of-shift reports. The nurse should not delay the meeting for change-of-shift
report by paying courtesy calls to staff members before attending the meeting.
Change-of-shift reports are not conducted in the presence of physicians, thus the
nurse does not need to wait for the physicians to arrive before exchanging notes. The
nurse should ask questions related to the medical record if any information is
unclear.
23.
A nurse is manually documenting information related to a client’s condition. When
documenting this information, the nurse makes an error on the manual record sheet.
Which is the best technique for recording the error made in
documentation?
A)
Erase the incorrect statement and write the correct one.
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Ans: B
B)
Cross out the wrong statement in a way that is not readable.
C)
Use correction fluid to obliterate what has been written.
D)
Cross out the incorrect statement with a single line.
Ans: D
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When recording an error in documentation, the nurse should always cross out the
incorrect statement with a single line so that it remains readable, add the date, initial,
and then document the correct information. The nurse should not erase the incorrect
statement and replace it with the correct one, nor cross out the wrong statement in a
way that makes the statement unreadable, nor use correction fluid to obliterate what
has been written. These methods render the medical record a poor legal defense.
A)
Information is documented in separate forms by each health care personnel.
B)
It is a unified, cooperative approach for resolving the client’s problems.
C)
It is organized at one location according to the client’s health problems.
D)
It is compiled to facilitate communication among health care professionals.
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24.
A nurse caring for a client who is being treated by three physicians uses the source-oriented
format for documentation.
What are the benefits of using this format of documentation?
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Ans: A
Feedback:
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Source-oriented documentation is a record organized according to the source of
documented information. This type of record contains separate forms on which
health care personnel make written entries about their own specific activities in
relation to the client’s care. The problem-oriented method of recording demonstrates
a unified, cooperative approach to resolving the client’s problems. Source-oriented
records are organized at numerous locations; there is not one location for
information. The problem-oriented record is compiled to facilitate communication
among health care professionals.
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A newly hired nurse is participating in the orientation program for the health care
facility. Part of the orientation focuses on the use of the SOAP (subjective, objective,
assessment, and plan) method for documentation, which the facility uses.
The nurse demonstrates understanding of this method by identifying which of the following as
the first step?
Plan of care
B)
Data, action, and response
C)
Problem selected
D)
Nursing activities during a shift
Ans: C
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A)
Feedback:
The SOAP method begins by selecting a problem from a list. PIE (problems,
interventions, and evaluation) notes incorporate the plan of care into the progress
notes. Focus DAR notes organizes entries by data, action, and response. The
narrative notes are used to record relevant client and nursing activities throughout a
shift.
26.
A nurse is documenting client information using PIE charting. Which information would the
nurse expect to document?
A)
Client assessment
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Ans: A
B)
Intervention carried out
C)
Written plan of care
D)
Multidisciplinary interventions
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Ans: B
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Feedback:
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In the PIE notes, the nurse documents the problem, intervention and evaluation. Thus
the nurse would document the intervention carried out. Client assessment is not a
part of the PIE notes, because this information is recorded on flow sheets for each
shift. Although the PIE system uses a nursing plan-of-care format, there is no written
plan of care. The PIE system is not multidisciplinary; it provides a documentation
system for nursing only.
What activity in charting will assist most in the avoidance of errors?
A)
Objectivity
B)
Organization
C)
Legibility
D)
Timeliness
Ans:
D
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Documentation in a timely manner can help avoid errors.
A)
PIE note
B)
Flow sheet
C)
Narrative note
D)
SOAP note
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28.
A nurse in a nursing home is writing a note that addresses the care a resident has received
during the day and the
resident’s response to care. What type of note does this represent?
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Ans: C
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A narrative note in a skilled nursing facility might include the type of morning care,
nutritional intake, client activity pattern, and comfort measures provided, along with
the client’s response.
A)
U (unit)
B)
QD (daily)
C)
NPO (nothing per os)
D)
mL (milliliters)
E)
> (greater than)
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29.
Which of the following abbreviations is on the list of the Joint Commission do not use
abbreviations? Select all that
apply.
Ans: A, B, E
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Feedback:
The words “unit”, “daily”, “greater than” and “less than” should be spelled out. NPO,
mL, and mcg are acceptable abbreviations.
A)
A nurse working in a physician’s office puts out a sign-in sheet for incoming clients.
B)
Two nurses are overheard talking about a client through the door of an empty client room.
C)
A nurse places a client chart in a holder on the examining room door with the name facing out.
D)
A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms.
E)
A nurse calls out the name of a client who is seated in the waiting room.
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30.
Which of the following are examples of incidental disclosures of client health information that
are permitted? Select all
that apply.
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Ans: A, B, E
Permitted incidental disclosures of PHI include using sign-in sheets without the
reason for visit; the possibility of a conversation being overheard if measures are
taken to be private; placing a client chart on the door with the face pages facing
inward; placing an x-ray on a light board as long as it is not unattended; calling the
name of a waiting patient; and leaving appointment reminders on answering machines
(provided only a minimal amount of information is given).
31.
Which of the following are examples of breaches of client confidentiality? Select all that
apply.
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A nurse discusses a client with a coworker in the elevator.
B)
A nurse shares her computer password with a relative of a client.
C)
A nurse checks the medical record of a client to see who should be called in an emergency.
D)
A nurse updates the employer of a client regarding the client’s return to work.
E)
A nurse uses a computer to document a client’s response to pain medication.
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A)
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Ans: A, B, D
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Nurses may use computers to document client data as long as they are not in a public
area, and as long as the computer is shut down following the entries. A nurse can
also check the medical record for a relative to call in case of an emergency. All the
other examples are violations of client confidentiality.
In which of the following cases should a progress note be written? Select all that apply.
A)
For any nurse–client interaction
B)
When admitting a client
C)
When receiving a client postoperatively
D)
When assisting a client with ADLs
E)
When a procedure is performed
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32.
Ans: B, C, E
Feedback:
A progress note should be written in the following instances: upon admission, transfer
to another unit, and discharge; when a procedure is performed; upon receiving a
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client postoperatively or postprocedure; upon communicating with physicians
regarding critical client information (e.g., abnormal lab value result); or for any
change in client status.
A)
Completely erase or delete the erroneous entry if possible.
B)
Use a highlighter to mark the incorrect entry and place initials next to it.
C)
Strike out the entry with a single line, place initials next to it, and write the correct entry.
D)
Black out the erroneous entry with a dark pen or marker.
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33.
A nurse realizes that the dosage of the medication administered to the client has been entered
incorrectly into the client
records. Which of the following would be most appropriate for the nurse to do?
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Ans: C
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Feedback:
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The nurse should strike out the erroneous entry with a single line and place initials
over it. When an error occurs, erasure or use of correction fluid is not permissible.
Use of highlighters is not allowed and can draw attention to the erroneous
documentation.
34.
The nurse notes that the blood glucose level of a client has increased and is planning
to notify the health care provider by telephone. Which of the following techniques
would be most appropriate for the nurse to use when communicating with
the health care provider?
A)
ISBAR
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B)
EMAR
C)
SOAP
D)
CBE
Ans: A
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Feedback:
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The nurse should use ISBAR to communicate verbally to the health care provider.
Identify/Introduction, Situation, Background, Assessment, and Recommendation
(ISBAR) is the communication tool to provide critical client information to the
health care provider. EMAR is Electronic Medication Administration Record, which
documents medication administration. SOAP is Subjective, Objective, Assessment,
and Plan, which is a progress note that relates to only one health problem. CBE is
Charting by Exception and permits the nurse to document only those findings that fall
outside the standard of care and norms that have been developed by the institution.
A)
The physician’s assessment and treatment
B)
Results of laboratory and diagnostic studies
C)
Nursing documentation and plan of care
D)
Information from other members of the health care team
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35.
The nurse is reviewing a client’s chart. When reading the history, physical, and physician
progress notes, the nurse
anticipates finding which of the following?
Ans: A
Feedback:
The medical history, physical examination, and progress notes record the findings of
physicians as they assess and treat the client. They focus on identifying pathologic
conditions and their causes, as well as determining the medical regimen for treatment.
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The nurse should utilize ISBARR communication (Introduction, Situation,
Read Back) during which of the
Background, Assessment, Recommendation, 36.
following clinical situations?
When communicating a client’s change in condition to the client’s physician
B)
When providing a change-of-shift report to a colleague
C)
When documenting the care that was provided to a client whose condition recently
deteriorated
D)
When reporting to a client’s family member or significant other
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A)
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Ans: A
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ISBARR communication is an increasingly common tool for interdisciplinary
communication. It is not typically used during change-of-shift report nor when
communicating with family members. ISBARR is considered a framework for
communication rather than a format for documentation.
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Chapter 21, Informatics and Health Care Technologies
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1. In informatics, raw, unprocessed numbers, symbols, or words that have no meaning by themselves
2)Data
3)Knowle
dge
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are called which of the following? 1)Information
4)Wisdo
m ANS:
2
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processed into a meaningful, structured form. Knowledge is formed when data are grouped,
creating meaningful information and relationships, which are then added to other structured
information. Wisdom is the appropriate use of knowledge in managing or solving human problems.
=
2. Which informatics concept concerns the appropriate use of knowledge in
managing or solving human problems? 1)Wisdom
2)Data
3)Knowle
dge
4)Informa
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ANS: 1
Extra training is not required for
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Wisdom is the appropriate use of knowledge in managing or solving human problems. Data are raw,
unprocessed numbers, symbols, or words that have no meaning by themselves. Information consists of
groupings of data processed into a meaningful, structured form. Knowledge is formed when data are
grouped, creating meaningful information and relationships, which are then added to other structured
information.
3. Computers are important for evidence-based practice because:
1) They are available in all healthcare institutions.
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information retrieval. 3)Information can be
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accessed and managed more efficiently.
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a computer. ANS: 3
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4)All of the best evidence is located on
To incorporate the current, best evidence in your nursing practice, you must be able to locate the
evidence, evaluate its quality and relevance to the problem, and apply the solution to clinical care.
Computers are useful for data access, management, storage, and retrieval when conducting research
or reviewing research findings. Specialized software aids in statistical analysis of research data.
Computers are not available to all personnel in all healthcare institutions nor can the entirety of best
evidence be found electronically. Training and experience are required to learn how to use a
computer as well as how to conduct a literature search.
4. You are a preceptor for a new nursing employee at the local hospital. She needs to access a
patients electronic health record (EHR) to retrieve laboratory results; however, the newly hired nurse
has not yet received a computer password. What action should you take?
1) Give her your password to use until she obtains her own password.
Log on and remain with her while she views the record.
3) Notify your supervisor that the new employee needs a password.
4) Inform her that she will not receive a password until her
2)
orientation is complete. ANS: 3
Never share your password with another person or log on to a computer to allow another
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supervisor
that the new employee needs a
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password. In most hospitals, nurses are given a password during their orientation.
5. Review the following: 38 years old; growth in height to 52; female gender; weight gain of
15 pounds. This list can be referred to as which of the following?
1)
Informa
tion
2)Knowle
dge
3)Data
4)Patient
record
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ANS: 1
Internet site.
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The segments are grouped into a meaningful, structured form and are considered together as
information. However, 38, 52, female, 15 standing alone would be examples of raw, unprocessed
numbers, symbols, or words that have no meaning by themselves and therefore would be data.
6. CINAHL is a(n):
1) Popular periodical.
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3)Scholarly
journal.
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4)Literature
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database ANS:
4
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CINAHL, The Cumulative Index of Nursing and Allied Health Literature, is a literature database
covering nursing, allied health, biomedical, and consumer health journal articles. CINAHL may be
accessed by the Internet or in hard copy in most libraries.
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7. A nurse is entering a pharmacy request for patient medication in the patients electronic
health record (EHR) while seated at a computer in the nursing station. A physician approaches her
and asks her to access another patients EHR so that he can look at the patients laboratory report.
Which of the following is the best action for the nurse to take?
1) Access the lab report for the physician.
Log off the computer before proceeding.
3) Quickly finish the pharmacy requisition before the physician logs on.
2)
4)
Allow the physician to access the laboratory report
without logging out. ANS: 2
Improved access to patient data
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2)
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physician order entry (CPOE)? 1)Increased privacy
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The nurse should log off the computer and then allow the physician to log on under his own
password. Accessing information that is not relevant to the care that the nurse is providing is a
HIPAA violation. Rushing to complete a pharmacy request for patient medication is a situation of
risk for medication error. The nurse should never hurriedly order or administer medication because
that is when errors are more likely to occur. The nurse should never allow anyone to use her
password to access information.
8. What is (are) the primary benefit(s) of computer
Cost savings
4) Reduced
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medication errors
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ANS: 4
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Computer physician order entry (CPOE) is technology that allows healthcare providers to enter
orders into a computerized prescribing system instead of handwriting them. Orders are integrated
with patient information, including allergy history and laboratory and other prescription data. The
new order is then automatically checked for potential errors or problems. This reduces prescription
errors resulting from illegible penmanship. It can detect dosing errors by flagging medication
dilution or dosages that fall outside normal dosing standards. The system warns about the possibility
of a drug interaction, allergy, or incorrect dose. As some drug names sound like other drugs, CPOE
can alert prescribers and potentially avoid a drug error that could be serious or fatal. Although the
efficiencies of the CPOE reduce costs, it is not the primary benefit of the system. Likewise, orders
entered into the computer are more conveniently accessed by nurses and pharmacists, but the most
important benefit of CPOE is to reduce errors.
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
1. Which of the following are main functions of a
computer? Choose all that apply. 1)Process
2)Storage
3)Memor
y
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4)Output
ANS: 1,
2, 4
2. Which of the following aspects of a computer determine its power? Choose all that apply.
1) User friendliness
2)
Speed of
operations
3)Accessibility for
the user
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4)Data storage
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capacity ANS: 2, 4
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The power of a computer is determined by its speed, accuracy, reliability, and data storage and
processing capabilities. Although ease of use and accessibility are important features for users,
these factors do not determine the power of a computer.
3. Which of the following health information is protected in the electronic health record? Choose
all that apply.
1) Social Security
number
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2)Insurance
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information
4)Laboratory
results ANS: 1, 2,
4
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3)Physicians
A patients protected health information includes any individually identifiable health information;
current, past, or potential physical or mental conditions; and any payment information, such as
Social Security numbers or insurance.
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4. The nurse is preparing to pass the 0900 medications prescribed for her patients. She
removes the medications from the automated dispensing unit. When scanning the medication, an
alert notifies the nurse that the patient is allergic to this medication. What action should the nurse
take? Choose all that apply.
1) Override the alert and administer the medication.
2) Confirm the patients allergies and type of reaction.
3) Notify the prescriber of the patient medication allergy.
4) Be sure an antidote is available at the
patients bedside. ANS: 2, 3
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necessary to make decisions. ANS: Informatics
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Alerts are configured to notify the nurse of potential adverse effects before the patient receives the
medication. Sometimes patients state they are allergic to a medication when, in reality, they may
only have experienced a side effect. The physician or pharmacist can be instrumental in discerning
if the patients reaction was a true allergy. The physician should always be notified before
administering medications when an allergy error has been received. Although an antidote to a
medication could be useful in the event of a harmful effect, the medication in the situation should
not be given, and therefore, the antidote would not be necessary.
Completion
Complete each statement.
1.
is the managing and processing of information
is the use of telecommunication to send healthcare information between
patients and professionals at different locations.
ANS: Telehealth
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2.
Facebook, MySpace, and LinkedIn are examples of
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3.
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tools. ANS: social networking
such as NIC, NOC, NANDA-I, and PNDS can be used to describe the unique
4.
nursing contributions to patient care. ANS: Standardized nursing languages
Standardized nursing languages communicate health information, promote evidence-based practice
using health records, decrease medical error, and protect patient privacy and confidentiality.
However, no single nursing language currently describes all of the aspects of nursings contribution
to care. Use of standardized terminology helps to match like terms within the electronic medical
record.
Chapter 22, Developing Concepts
1.
A child demonstrates increasing language skills and an understanding of symbols.
Creative play and the use of imagination is an important activity in the child’s life.
Based upon these characteristics and according to Jean Piaget’s
theory, what stage of cognitive development is the child demonstrating?
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Preoperational stage
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B)
Sensorimotor stage
C)
Concrete operational stage
D)
Formal operational stage
Ans: A
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The preoperational stage (ages 2 to 7 years) is characterized by the beginning use of
symbols, through increased language skills and pictures. Play activities during this
time help the child understand life events and relationships. The sensorimotor stage
(birth to 24 months) is marked by stages that begin with the demonstration of basic
reflexes through beginning development in reasoning skills. The concrete operational
stage (ages 7 to 11 years) is characterized by the development of logical thinking, an
understanding of reversibility, relations to numbers, and the loss of egocentricity.
The formal operational stage (age 11 years and older) is characterized by the use of
abstract thinking and deductive reasoning.
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2.
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A female client age 35 years explains to the community health nurse that her primary
focus daily is the care of her family, her job, and her volunteer activities at her
church. The client verbalizes contentment with her various roles and the balancing of
these roles. According to the theory on “individual life structure” developed by
Daniel Levinson and
associates, this client is demonstrating characteristics associated with what phase of
adulthood?
A)
Settling down
B)
Early adult transition
C)
Entering the adult world
D)
Midlife transition
Ans: A
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In the settling-down phase (age 30-40), the adult invests energy into the areas of life
that are most important, such as family, work, and community. The years of the
middle to late 20s (age 22-28) are a time to build on previous decisions and choices,
and to try different careers and lifestyles. It is defined as the phase of “entering the
adult world.” During early adult transition, the major concerns of the young adult
(age 18-22) are to break away from the parents, to make initial career choices, and to
establish intimate relationships. Midlife transition (age 40-45) involves a reappraisal
of one’s goals and values.
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Intuitive–Projective Faith
B)
Mystical–Literal Faith
C)
Synthetic–Conventional Faith
D)
Individuative–Reflective Faith
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A)
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3.
A child who attends church with his parents imitates religious gesture but does not
have an understanding of these religious behaviors. The child also asks his parents,
“How do you know God exists? Have you ever seen him?” This
child is described as having characteristics associated with which stage of faith development
as defined by Fowler?
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Ans: A
The child is demonstrating characteristics of the stage of Intuitive–Projective Faith.
During this stage, the child takes on parental attitudes toward religious or moral
beliefs without an understanding of them. During the Mystical–Literal Faith stage, the
child accepts the existence of a deity. Synthetic–Conventional Faith is the
characteristic stage for many adolescents when they begin to question life-guiding
values or religious practices in an attempt to stabilize their own
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identity. The Individuative–Reflective Faith stage often occurs during the older
adolescent and young adult years, as individuals become responsible for their own
commitments, beliefs, and attitudes.
A)
Preconventional level: stage 1
B)
Preconventional level: stage 2
C)
Conventional level: stage 1
D)
Conventional level: stage 2
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4.
After a child plays in the yard, his mother asks him to pick up his toys and put them
in the toy bin in the garage. Knowing that he does not want to spend time in his room
as a punishment, the child follows his mother’s directions.
What stage of moral development, according to Kohlberg, is this child demonstrating?
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The preconventional level is based on external control as the child learns to conform
to rules imposed by authority figures. At stage 1 (punishment and obedience
orientation), the motivation for choices of action is fear of physical consequences of
authority’s disapproval. At stage 2 (instrumental relativist orientation), the thought of
receiving a reward overcomes fear of punishment, so actions that satisfy this desire
are selected. The conventional level involves identifying with significant others and
conforming to their expectations.
5.
A boy age 4 years is constantly seeking out and exploring new experiences, and
repeatedly asking his parents why-type questions. The boy’s behavior suggests that
he is successfully navigating an important developmental task within the
developmental theory of:
A)
Erikson
B)
Freud
C)
Kohlberg
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D)
Fowler
Ans: A
Feedback:
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Erikson characterized development as a series of crises. The preschooler typically
must choose between initiative (seeking new experiences and learning) and guilt.
Freud focuses on psychosexuality while Kohlberg prioritizes moral development.
Fowler explains development through the lens of faith.
A)
Accepting and adjusting to physical changes
B)
Adjusting to reduced income
C)
Adjusting to decreasing health
D)
Learning to live with a marriage partner
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6.
Which of the following developmental tasks is an important component of middle adulthood
within Havighurst’s theory
of psychosocial development?
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Feedback:
Havighurst identifies the acceptance and adjustment to physical changes as a task
associated with middle adulthood. Adjusting to declining health and reduced income
are associated with later maturity, while learning to live with a marriage partner is a
developmental task of young adulthood.
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A)
Gilligan
B)
Kohlberg
C)
Gould
D)
Fowler
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7.
A nurse provides care in a women’s health clinic that is located in an inner city neighborhood.
Which of the following
theorists’ work applies most directly to this nurse’s client population?
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Carol Gilligan’s work specifically addresses the moral development of women,
proposing an ethic of care that develops through three levels during women’s lives.
Kohlberg, Gould, and Fowler do not differentiate between the developmental
considerations of males and females.
Which of the following nurses is most likely to care for clients who are trying to resolve
identity versus role confusion?
A)
A nurse who provides care in a large junior high school
B)
A pediatric nurse
C)
A nurse who works in a long-term care facility
D)
An occupation health nurse based at a lumber mill
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8.
Ans: A
Feedback:
According to Erikson, the crisis of identity versus role confusion is characteristic of
adolescence. Consequently, anurse who provides care in a junior high school is likely
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to see frequent manifestations of this crisis. Early childhood, middle adulthood, and
late adulthood are not typical life stages for the resolution of this crisis.
A child gains weight and becomes taller each year. What is this process called?
A)
Development
B)
Orderly change
C)
Progression
D)
Growth
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Growth is an increase in body size or changes in body cell structure, function, and
complexity. Development is an orderly pattern of changes in structure, thoughts,
feelings, or behaviors resulting from maturation, experiences, and learning.
A)
Development
B)
Growth
C)
Maturity
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10.
All humans learn from both formal and informal experiences. What orderly pattern of changes
results in part from
learning?
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D)
Aging
Ans: A
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Development is an orderly pattern of changes in structure, thoughts, feelings, or
behaviors resulting from maturation, experiences, and learning. It is a dynamic and
continuous process as one proceeds through life, characterized by a series of ascents,
plateaus, and declines. Growth is an increase in body size or changes in body cell
structure, function, and complexity.
A)
Legs and feet develop first.
B)
Both sides of the body develop equally.
C)
Head and brain develop first.
D)
Gross motor skills are learned last.
Ans: C
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11.
As the fetus develops, certain growth and development trends are regular and predictable. The
first trend is
cephalocaudal growth. What does this mean?
Feedback:
Cephalocaudal (proceeding from the head to the tail) development is the first trend,
followed by proximodistal (progressing from gross motor to fine motor movements),
and finally by symmetric (both sides of the body developing equally).
12.
Many different factors affect growth and development. For example, why does one child have
blonde hair and blue eyes
while another child has brown hair and green eyes?
A)
Childhood illnesses
B)
Genetic inheritance
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C)
Prenatal influences
D)
Maternal nutrition
Ans: B
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At conception, every human receives an equal number of chromosomes from each
parent. Physical characteristics, such as height, bone size, and eye and hair color, are
inherited from our family of origin.
A)
To establish a sense of security
B)
To establish a sense of identity
C)
To gain autonomy
D)
To avoid inferiority
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13.
According to Erikson, normal adolescent behavior includes trying on new roles and possibly
even rebelling. What is the
purpose of this behavior in adolescents?
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According to Erikson, the developmental task for adolescents is identity versus role
confusion. Trying on new roles and even rebelling are normal behaviors as the
adolescent acquires a sense of self and decides what direction to take in life. The
other choices are not appropriate for adolescents.
A)
Cognitive
B)
Intellectual
C)
Moral
D)
Psychosocial
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14.
A school-aged child always follows the rules and obeys traffic lights when crossing the street.
Based on Kohlberg’s
theory, what type of development is being demonstrated?
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Kohlberg’s theory of moral development includes the stages through which
individuals move. School-aged children obey rules and regulations established by
society and enforced by authority figures.
15.
In contrast to Kohlberg, Gilligan developed a theory of moral development specifically for
women. What is the central
theme of Gilligan’s theory?
A)
Response and care
B)
Rights and justice
C)
Adult transformation
D)
Individual life structure
Ans: A
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Feedback:
Gilligan’s theory, developed to explain the female viewpoint of morality as different
from that of Kohlberg, views females as developing a morality of response and care
and males as developing a morality of justice, rights, and obligation.
A)
Undifferentiated faith
B)
intuitive–projective faith
C)
mythical–literal faith
D)
synthetic–conventional faith
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16.
A child 7 years of age attending a Roman Catholic Mass with his parents stands and holds his
hymnal to sing the
opening song. According to Fowler, what stage of development is this child experiencing?
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Intuitive–projective faith is most typical of the 3- to 7-year-old child. Children
imitate religious gestures and behaviors of others, primarily their parents. They take
on their parents’ attitudes toward religious or moral beliefs without a thorough
understanding of them. Imagination in this stage leads to long-lived images and
feelings that they must question and reintegrate in later stages.
17.
A child 2 years of age is hospitalized for a surgical procedure. Although previously all fluids
were taken from a cup, the
toddler wants a bottle to suck on. The nurse recognizes this behavior as what?
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A)
Totally unacceptable
B)
Proof that the child is sick
C)
Normal regression
D)
Abnormal behavior
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Based on the principles and theories of growth and development, the nurse
recognizes possible regression during difficult periods or times of crisis, accepting
and supporting a return to a forward progression in development. It is acceptable,
normal behavior for the hospitalized toddler.
Which developmental theory suggests success in achieving developmental tasks during later
stages of life?
A)
Kohlberg’s theory
B)
Piaget’s theory
C)
Havighurst’s theory
D)
Kubler-Ross’ theory
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18.
Ans: C
Feedback:
Havighurst’s theory of development suggests that success in achieving
developmental tasks leads to success with tasks in later stages of life.
19.
Which of the following actions would generally take place in the settling down stage of Daniel
Levinson’s Individual
Life Structure theory? Select all that apply.
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Breaking away from the family
B)
Making initial career choices
C)
Trying new lifestyles
D)
Striving to gain respect
E)
Investing in family
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In the settling-down phase (age 30–40), the adult invests energy into the areas of life
that are most personally important. The areas of investment are primarily family,
work, and community. The individual strives to gain respect, status, and a sense of
authority. Breaking away from family occurs in the early adult transition. Making
initial career choices and trying new lifestyles occurs in the entering-the-adult-world
stage. Maximizing self-approval occurs in the pay-off years.
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20.
Which of the following statements accurately describes factors that may affect an individual’s
growth and development?
Select all that apply.
A)
Physical characteristics such as height, bone size, eye color, and hair color are inherited from
the family of origin.
B)
Fetal development can be altered by maternal age, inadequate maternal nutrition or substance
abuse.
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C)
Abuse of alcohol and drugs is more prevalent in teenagers who have poor family relationships,
low self-esteem, and
poor social skills.
D)
Infants who are malnourished in utero develop fewer brain cells than infants who have had
adequate prenatal nutrition.
E)
Environmental factors such as poverty and violence do not have a direct effect on growth and
development.
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Physical characteristics, such as height, bone size, eye color and hair color, are
inherited from our family of origin. Fetal development can be altered by maternal age
(with risk greater in those under age 15 and over age 35), substance abuse, inadequate
prenatal care, inadequate maternal nutrition, and maternal substance abuse. Abuse of
alcohol and drugs is more prevalent in teenagers who have poor family relationships,
low self-esteem, and poor social skills. Infants who are malnourished in utero develop
fewer brain cells than infants who have had adequate prenatal nutrition.
Environmental factors that might alter development include poverty and violence.
The effect of each can occur independently, but they are more likely to be
interrelated. Prenatal, individual, and caregiver factors influence development in
many ways.
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21.
The nurse is seeing a pregnant woman 25 years of age. The woman’s partner is very
caring and loving, but has decided that he does not want to be a father, and so has left
the relationship. The woman is determined to raise her child alone
and says, “I will never let myself be hurt like that again.” According to Gilligan’s theory, on
which level is this woman?
A)
Level 1: Selfishness
B)
Level 2: Undifferentiated Faith
C)
Level 3: Goodness
D)
Level 4: Nonviolence
Ans: A
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Feedback:
Level 1 of Gilligan’s theory says that relationships are often disappointing, and as a
result, a woman might isolate herself to avoid getting hurt. Undifferentiated faith is
part of Fowler’s theory, not Gilligan’s. Goodness is Level 2 of Gilligan’s theory and
says that acceptance by others is very important. Nonviolence is Gilligan’s Level 3,
and it says that nonviolence has to do with all judgments and decisions.
A)
The pay-off years
B)
Later maturity
C)
Generativity versus stagnation
D)
Postconventional level
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22.
The nurse is caring for a woman 55 years of age who has been admitted for a hernia
repair. The nurse is doing an initial nursing assessment and considers developmental
theories. Where would the nurse place the client according to the
theory of Daniel Levinson and associates?
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Levinson and associates describe the pay-off years as the years from 45 to 65. They
are a time of maximum self- direction and self-approval. Physical and mental
changes increase an awareness of one’s aging and mortality. The postconventional
level is a stage described by Lawrence Kohlberg. Later maturity is a stage described
by Robert Havighurst. Generativity versus stagnation is appropriate for this client’s
age, but is a theory stage of Erik Erikson.
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A)
Autonomy
B)
Identity
C)
Intimacy
D)
Initiative
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23.
A mother brings her toddler, age 20 months, to the clinic today for immunizations.
She talks about trying to initiate toilet training a few weeks ago, but her son wasn’t
interested. She decided to put it off for awhile. She told her son he was a good boy
and they would try again another time. According to Erik Erikson’s theory, what is
the likely outcome for
Matt’s developmental stage?
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Autonomy versus shame and doubt implies that if the caregivers are overprotective or
have expectations that are too high, shame and doubt, as well as feelings of
inadequacy, might develop in the child. The mother has a good attitude towards toilet
training and from that, her son will develop his autonomy. Initiative has to do with
Erikson’s theory about preschool-aged children. Identify is related to adolescence,
and intimacy is about young adulthood.
24.
A nursing student is assisting the school nurse with a middle school health fair. The
student does height and weight assessments on the students. As the nursing student
assess them, the student observes that the students are able to use
deductive reasoning and think in abstract ways. According to Piaget, in what development
stage are they?
A)
Genital
B)
Identity versus role confusion
C)
Formal operational
D)
Gender role acceptance
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Ans: C
Feedback:
Piaget owns the formal operational theory stage that is characterized by the use of
abstract thinking and deductive reasoning. Freud’s theory of the genital stage
indicates sexual interest can be expressed in overt sexual relationships. Sexual
pressures and conflicts typically cause turmoil as the adolescent makes adjustments in
relationships. Identity versus role confusion is Erikson’s stage for adolescents. The
stage of gender role acceptance belongs to Havighurst.
A)
Trust
B)
Autonomy
C)
Initiative
D)
Identity
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25.
The emergency department nurse is caring for an infant age 2 months who was
brought in by a hired caregiver. The infant is underweight and looks uncared for.
The caregiver reports that the mother of the infant is unreliable and may be using
drugs; the infant is often unclean and hungry when dropped off at the caregiver’s
home. The infant has diaper rash and a weak cry. If this situation is not remedied,
what will this infant have difficulty achieving, according to Erikson’s
developmental theory?
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The infant learns to rely on caregivers to meet basic needs of warmth, food, and
comfort. This is how the infant learns to form trust in others. Mistrust is the result of
inconsistent, inadequate, or unsafe care. The other choices are later stagesof Erikson’s
developmental theory.
A)
Age of mother
B)
Prenatal nutrition
C)
Substance abuse by mother
D)
Congenital vision deficit
E)
Poor neonatal nutrition
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26.
The nurse is working in the newborn nursery and observes neonates in various states of health
and wellness. The nurse is
aware that which of the following factors can affect fetal development? Choose all that apply.
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Ans: A, B, C
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Fetal development can be altered by maternal age (with risk greater in those under
age 15 or over age 35), substance abuse, inadequate prenatal care, inadequate
maternal nutrition, and maternal substance abuse. Congenital abnormalities and poor
neonatal nutrition do not affect fetal development.
27.
The nurse is educating a high school health and fitness class about substance abuse.
One of the group members asks what happens if a pregnant woman is using drugs.
The nurse’s best replies include which of the following? Choose all
that apply.
A)
Low birth weight
B)
Premature births
C)
Regular prenatal care
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D)
Congenital anomalies
E)
Risk of poor nutrition
Ans: A, B, D, E
Feedback:
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Substance abuse by a pregnant woman increases the risk for congenital anomalies,
low birth weight, and prematurity in her developing fetus. Someone who is using
drugs is less likely to eat a nutritious diet and have regular prenatal care.
A)
Nutritional deprivation
B)
Working mothers
C)
Use of day care centers
D)
Premature births
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28.
A nursing student is observing in a pediatric clinic. A grandmother brings an infant
age 2 months to be seen. The infant has failed to gain the expected amount of weight
and looks unwell. The nursing student wonders if this may be a failure
to thrive baby. Which one of the following has been linked to failure to thrive babies?
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Failure to thrive, a condition of early infancy, has been linked to both nutritional and
emotional deprivation. This list is not all inclusive. Use of day care centers by
working mothers has not been noted as a factor contributing to failure to thrive, nor
have premature births.
A)
Lessens teething pain
B)
Major source of gratification
C)
Sucking is a basic reflex
D)
Assists in gaining confidence
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29.
A nurse is caring for a child age 13 months who was admitted to the pediatric unit
with a new diagnosis of asthma. The mother tells mentions how frustrated she gets
because the baby puts everything in her mouth, even things that are not clean. The
nurse knows that according to Freud’s theory of growth and development, which of
the following explains
this behavior?
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According to Freud, during the oral stage, the infant uses his or her mouth as the
major source of gratification and exploration. Pleasure is experienced from eating,
biting, chewing, and sucking. This provides the infant with security. Chewing on
things probably does lessen teething pain and sucking is a basic reflex, but neither of
these things are part of Freud’s theory. Putting things in the mouth is not connected
with gaining confidence.
30.
The nursing student is visiting a middle school with an assignment to observe and
visit with students while walking around with the school nurse. Then nursing student
is interested to learn that some students seem to be rebelling against authority figures
like teachers and parents. The nursing student recalls that, according to Erikson’s
theory, this is not
abnormal behavior. To which stage of Erikson’s theory does this behavior belong?
A)
Identity versus role confusion
B)
Industry versus inferiority
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C)
Initiative versus guilt
D)
Autonomy versus shame
Ans: A
Feedback:
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Trying on roles and even rebellion are considered normal behaviors as the adolescent
acquires a sense of self and decides what direction will be taken in life. Role
confusion occurs when the adolescent is unable to establish identity and a sense of
direction. The other choices are different stages of Erikson’s theory.
A)
Industry versus inferiority
B)
Latency
C)
Acceptance of deity
D)
Concrete operational
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31.
A nursing student is visiting a third-grade class to observe growth and development
in action and does assessments on the children. They are learning to think logically
and to classify and relate objects and ideas. According to Erikson, in
what developmental stage are they?
Ans: A
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Third graders are in Erikson’s industry versus inferiority stage. Focusing on the end
result of achievements, the school- aged child gains pleasure from finishing projects
and receiving recognition for accomplishments. Concrete operational is Piaget’s
theory for school-aged children. Latency is Freud’s theory. Acceptance of a deity is a
developmental theory belonging to Fowler.
Proceeds from brain down to feet
B)
Both sides of the body develop equally
C)
Brain must fully develop before toilet training
D)
Gross control to fine control
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32.
The nurse is caring for a an infant age 11 months. The infant’s mother tells states that
when she asked the doctor about starting to toilet train her child, the doctor talked
about cephalocaudal development. The mother then asks for an
explanation of this term. Which of the following about cephalocaudal development is the
nurse’s best reply?
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Ans: A
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Cephalocaudal (proceeding from head to tail) development is the first trend, with the
head and brain developing first, followed by the trunk, legs, and feet. The second
trend is proximodistal development, which means that growth progresses from gross
motor movements (such as learning to lift one’s head) to fine motor movements
(such as learning to pick up a toy with the fingers). The last trend is symmetric
development of the body, with both sides of the body developing equally.
33.
Then nurse is caring for single, professional woman age 29 years, who was admitted
with a severe gall bladder attack. The nurse visits with her and performs an
assessment. The client is not married and fears a committed relationship because of a
bad experience some years ago. The nurse knows that, according to Erikson’s
developmental theory, Judith
is in danger of which of the following?
A)
Isolation
B)
Inferiority
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C)
Role confusion
D)
Stagnation
Ans: A
Feedback:
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Erikson’s theory of young adulthood relates to finding one’s life partner and sharing
intimacy. The tasks for the young adult are to unite self-identity with identities of
friends and to make commitments to others. Fear of such commitments results in
isolation and loneliness. Role confusion, inferiority, and stagnation are related to
Erikson’s other age groups.
2.
Sit up alone
3.
Crawl
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The nurse is working on the pediatric unit today and caring for a girl age 8 months
who is admitted with a respiratory infection. As the nurse assesses her, the mother
notes that she thinks her daughter is ready to walk. The nurse explains cephalocaudal
development to her and why walking may take a little longer to happen. The nurse
also provides some information about appropriate expectations. Place the following
developmental abilities in order according to cephalocaudal progression.
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4.
Walk
5.
Run
6.
Skip
1, 2, 4, 6, 3, 5
B)
1, 3, 2, 4, 5, 6
C)
1, 2, 3, 4, 5, 6
D)
1, 2, 4, 3, 6, 5
E)
2, 1, 3, 4, 5, 6
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Growth and development follow regular and predictable trends. Cephalocaudal
(proceeding from head to tail) development is the first trend, with the head and brain
developing first, followed by the trunk, legs, and feet.
The nurse is working on the pediatric unit today and caring for an infant age 3
months who is admitted with a respiratory infection. As the nurse assesses her, the
mother tells states that she thinks the baby is ready to feed herself. The nurse explains
proximodistal development to the mother and why self-feeding may take a little
longer to happen. The nurse provides some information about appropriate
expectations. Place the following developmental abilities in order according to
proximodistal progression.
1.
Waving arms
2.
Lifting head
3.
Holding a spoon
35.
4. Picking up a grain of rice
A)
1, 2, 3, 4
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B)
2, 1, 3, 4
C)
3, 1, 2, 4
D)
2, 3, 1, 4
Ans: B
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Proximodistal development means that growth progresses from gross motor
movements (such as learning to lift one’s head) to fine motor movements (such as
learning to pick up a toy with the fingers).
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Chapter 23, Conception Through YoungAdulthood
A)
Adequate intake of food and fluids
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1.
A nurse is teaching a young woman about healthy behaviors during the embryonic stage of
pregnancy. Which of the
following should the nurse emphasize to prevent congenital anomalies?
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B)
Importance of rest and sleep
C)
Avoid alcohol and nicotine
D)
Progression of stages during delivery
Ans: C
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The embryonic stage of prenatal development occurs from the fourth to the eighth
week of pregnancy. Because this is a period of rapid growth and change, the fetus is
especially vulnerable to any factor that might cause congenital anomalies, such as
maternal use of alcohol and nicotine. Although the other choices are appropriate in
educating the pregnant woman, they do not prevent congenital anomalies.
A)
Vitamin D
B)
Iodine
C)
Calcium
D)
Folic acid
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2.
A nurse is teaching a pregnant woman about nutritional needs. Which of the following
nutritional deficiencies during
pregnancy might result in neural tube defects in the developing fetus?
Ans: D
Feedback:
During pregnancy, maternal nutrition is essential for normal fetal growth and
development. Folic acid deficiencies might result in neural tube defects in the infant.
3.
At birth, the neonate must adapt to extrauterine life through several significant physiologic
adjustments. Which of the
following is the most important adjustment that occurs?
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A)
Body temperature responds to the environment
B)
Reflexes develop
C)
Stool and urine are eliminated
D)
Breathing begins
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Ans: D
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At birth, the neonate must adapt to extrauterine life through several significant
physiologic adjustments. The most important occur in the respiratory and circulatory
systems as the neonate begins breathing and becomes independent of the umbilical
cord.
B) 3
C) 4
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A) 2
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A nurse documents the following data upon assessment of a neonate: heart rate 89 BPM, slow
respiratory effort, flaccid
muscle tone, weak cry, and pale skin tone. What would be the Apgar score for this neonate?
D) 5
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Ans: B
Feedback:
The neonate is assessed immediately after birth. Of several existing measurement
scales, the Apgar rating scale is the most commonly used. This scale is used to
assess neonates 1 minute and 5 minutes after birth. This baby would receive 1 point
for slow heartbeat, 1 point for slow respiratory effort, and 1 point for weak cry.
Flaccid muscle tone and pale skin tone are both 0 points.
A)
left side.
B)
right side.
C)
abdomen.
D)
back.
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5.
A nurse is teaching a group of parents about the dangers of Sudden Infant Death Syndrome
(SIDS). The nurse
recommends that parents place their children on a firm surface laying on their:
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Ans: D
Feedback:
Because sleep habits have been implicated with SIDS, it is recommended that healthy
infants up to the age of 6 months sleep on their back (rather than the stomach) on a
firm surface in a safety-approved crib. Placing infants in a side-lying position is not
recommended because babies who sleep on their sides are more likely to roll onto
their abdomen.
6.
A nurse is observing a group of toddlers at play. What behavior illustrates normal physiologic
development in children
of this age?
A)
Attempting to feed self
B)
Using fingers to pick up small objects
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C)
Throwing and catching a ball
D)
Understanding the feelings of others
Ans: B
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Toddlers, aged 1 to 3, can pick up small objects with their fingers. The other
responses are characteristic of other stages of physiologic development: Infants
attempt to feed themselves; preschoolers can throw and catch balls; school-aged
children understand the feelings of others (cognitive, not physiologic, development).
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7.
A nurse watches as a child continuously tells her mother “no!” to each comment the mother
makes. The nurse knows
that this behavior, termed negativism, is characteristic of which of the following
developmental groups?
Toddler
B)
Preschooler
C)
School-aged child
D)
Adolescent
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A)
Ans: A
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Negativism (characteristically expressed by saying no) and outbursts of temper
result from the toddler’s efforts at control over the environment.
A preschooler is in Kohlberg’s preconventional phase of moral reasoning. What is the focus of
the phase?
A)
To learn sex differences and modesty
B)
A sexual desire for the opposite sex
C)
Obeying rules to avoid punishment
D)
Literal concept of God as a male human
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The focus of the preschooler, based on Kohlberg’s theory, is on obeying rules to
avoid punishment and receive a reward. Although the other responses are
characteristic developments of the preschooler, they are not components of moral
development.
Which of the following sets of terms best characterizes the school-aged child?
A)
Reflexes, alert state, temperament
B)
Negativism, regression, anal stage
C)
Preoperational, asking “why,” fears
D)
Doing, succeeding, accomplishing
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Ans: D
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The school-aged child is in the industry-versus-inferiority stage of Erikson’s theory,
with a focus on learning useful skills and developing positive self-esteem. The
emphasis is on doing, succeeding, and accomplishing.
A)
Parents
B)
Peers
C)
Siblings
D)
Grandparents
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10.
What social group prepares the school-aged child to get along in the larger world and teaches
appropriate sex role
behavior?
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Peer groups in middle childhood help prepare the child for getting along in the larger
world and teach appropriate sex role behavior. They also act as transition models for
the child in leaving the caregiver influence and moving toward adult independence.
A)
Adult secondary sex characteristics are present
B)
Ova and sperm are produced by the reproductive organs
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11.
A student nurse reading a client’s chart notes that the physician has documented an adolescent
as prepubescent. What
does the term prepubescent mean?
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C)
Reproductive organs do not yet produce ova and sperm
D)
Active sexual behavior has been initiated
Ans: C
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Puberty can be divided into three stages. In the first stage—prepubescence—
secondary sex characteristics begin to develop but the reproductive organs do not yet
function.
A)
Overcoming low self-esteem
B)
Becoming independent of one’s family
C)
Establishing one’s own moral philosophy
D)
Demonstrating industry and spirituality
Ans: B
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12.
A college student 20 years of age is preparing for a career as a teacher. What need initially
influences the decision to
establish a career?
Feedback:
A major psychosocial developmental requirement for the young adult is choosing a
vocation. The decision to enter the world of work is strongly influenced initially by
the need to become independent of one’s family and to be self- sufficient.
13.
A nurse is teaching a young couple about the normal changes during pregnancy. What should
be included in the teaching
sessions about the expectant father’s role?
A)
Nothing, the mother’s preparation is more important.
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B)
In a traditional family, the mother is responsible for child care.
C)
The importance of feeling pride as a future parent.
D)
The provision of support in meeting maternal needs.
Ans: D
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During pregnancy, the expectant father needs to learn the normal physiologic and
psychological changes of pregnancy, explore his feelings about the developing infant
and birth, and accept his supportive role in meeting maternal needs.
What is the primary risk to the developing fetus during pregnancy if there is cocaine use by
the mother?
A)
Decreased fetal circulation and oxygenation
B)
Increased maternal weight gain and edema
C)
Neural tube defects and low birth weight
D)
Respiratory difficulties and excess mucus
Ans: A
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14.
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The maternal use of cocaine during pregnancy brings about abrupt changes in the
mother’s blood pressure, resulting in decreased fetal blood flow and oxygenation.
A)
Colic
B)
Seborrheic dermatitis
C)
Failure to thrive
D)
SIDS
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15.
A nurse is educating the parents of an infant about possible health problems during infancy.
Which of the following
health problems during infancy is most serious?
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SIDS (sudden infant death syndrome) is the sudden death of an infant under the age
of 1 year, unexpected in light of the infant’s history, in which a postmortem
examination fails to reveal a cause of death. It is the leading cause of death in infants
aged 1 week to 1 year.
16.
A nurse is explaining ADHD to a community parents group. What characteristics of this
disorder are exhibited by an
affected child?
A)
Daydreams, math difficulties, speech problems
B)
Inattention, impulsiveness, hyperactivity
C)
Enuresis, shyness, scoliosis
D)
Separation anxiety, reading difficulties, boredom
Ans: B
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Feedback:
ADHD is a developmentally inappropriate degree of inattention, impulsiveness, and
hyperactivity. To be diagnosed, the child must have manifested symptoms before the
age of 7 years, and the symptoms must be present in at least two settings.
An adolescent client tells the nurse, “I just don’t want to live anymore.” What should the nurse
do next?
A)
Document the adolescent’s statement in the client record.
B)
Sit down and discuss all the reasons there are for living.
C)
Make an immediate referral to a suicide-prevention professional.
D)
Laughingly, teach the adolescent about making scary statements.
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Ans: C
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Suicide is the third leading cause of death in adolescents and young adults. Verbal or
nonverbal indicators of suicide should not be ignored; rather, an immediate referral
should be made to a professional trained in suicide prevention.
18.
A mother of three children under the age of 4 tells the nurse, “I don’t understand why my
children are so hard to toilet
train before they are 2.” How should the nurse respond?
A)
“Bladder control during the day usually occurs by ages 2.5 to 3 years.”
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B)
“Do you think you are doing something wrong? They should be trained.”
C)
“I don’t know. I will have to talk to your doctor, and I will let you know.”
D)
“I had that same problem. You just have to try harder.”
Ans: A
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Toddlers between the ages of 2.5 and 3 years usually have bladder control during the day and
sometimes at night.
A)
Lowering temperatures on hot water heaters
B)
Covering electrical outlets with safety prongs
C)
Removing all cords from mini-blinds and drapes
D)
Using special car safety seats and restraints
Ans: D
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19.
A nurse is teaching a group of expectant parents about infant safety. Which of the following is
mandated by the law to
promote infant safety?
Feedback:
Preventive measures against safety hazards must be taught to new parents. The law
mandates the use of special car safety seats and restraints for infants. The other
choices are important safety considerations, but they are not mandated by law.
20.
A student nurse is assigned to care for a preschool child who is scheduled for surgery. How
can the student decrease the
child’s fears about the surgery?
A)
Explain that nothing is going to hurt and that it will soon be over.
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B)
Be honest about pain and use words the child can understand.
C)
Ask the child’s parents to pretend that nothing is going to be done.
D)
Ignore the child’s fears and focus on teaching the parents.
Ans: B
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Preschool-aged children who are scheduled for surgery or hospitalization have many
fears. The nurse can help decrease fears by explaining procedures in language the
child can understand and by being honest about how much pain a procedure will
cause. The other choices would not be honest nor help the child.
Which of the following would be an appropriate topic for a nurse to present at an elementary
school PTA meeting?
A)
Prevention of congenital anomalies
B)
Dangers of smoking and drinking during pregnancy
C)
Importance of bonding and attachment
D)
Commonality of communicable diseases
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21.
Ans: D
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With increased interactions with other children in school, communicable conditions,
such as scabies, impetigo, and head lice, are more prevalent. The other choices are
not appropriate educational topics for parents of elementary school children.
A)
Proper hygiene
B)
Condom use
C)
Relationships
D)
Stress
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22.
A young adult tells the nurse that he has been sexually active with his girlfriend. What
teaching is most important for
this individual?
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Adolescents and young adults who engage in unprotected sexual intercourse are at a
higher risk for contracting sexually transmitted diseases (and their complications)
than are adults. All STDs, especially AIDS, pose serious health threats.
23.
A school nurse is concerned about the almost skeletal appearance of one of the high
school students. Although all of the following nutritional problems can occur in
adolescents, which one is most often associated with a negative selfconcept?
A)
Eating fast foods
B)
Obesity
C)
Fad dieting
D)
Anorexia nervosa
Ans: D
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Feedback:
Fad diets, eating fast foods, and obesity are common nutritional problems in
adolescents. However, the most common severe eating disorders are anorexia nervosa
and bulimia, which almost always involve a negative self-concept.
A)
Role modeling
B)
Intimacy versus isolation
C)
Law-and-order orientation
D)
Autonomy versus shame and doubt
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24.
An girl age 18 years has chosen not to attend a party in which alcohol will be consumed.
Which value system is she
most likely adhering to?
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Adolescents have a high level of moral judgment, with a law-and-order orientation.
25.
A woman is visiting the office and is in her third trimester of pregnancy. She asks the nurse
about the development that
is occurring at this stage of pregnancy. Which is accurate to tell her about the fetus?
A)
The lungs are mature.
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B)
The fetus is 11 to 14 inches.
C)
The arms and legs are reflexive.
D)
The head circumference is 34 cm.
Ans: A
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In the third trimester, the lungs are mature.
A)
Reaching for objects
B)
Staring at objects
C)
Kicking at objects
D)
Selecting specific objects
Ans: B
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26.
The nursing student is assessing a neonate who has been brought to the clinic for a well-baby
visit. Which of the
following would the nursing student expect as normal development for a neonate?
Feedback:
Neonates stare at objects, but are not capable of reaching, kicking or selecting objects at this
phase of development.
27.
A)
The nurse is educating the mother of an infant age 4 months on safety concepts in child
rearing. Which of the following
statements by the mother suggests that she may require some repetition and reinforcement of
the information?
I must keep small objects out of the baby’s reach.
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B)
The baby will sleep in her crib, not with me and my husband.”
C)
I must keep appointments for the baby’s immunizations.
D)
The baby can sleep on her stomach during naps.
Ans: D
Feedback:
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Because sleep habits have been implicated with SIDS, it is recommended that healthy
infants up to the age of 6 months sleep on their back (rather than the stomach) on a
firm surface in a safety-approved crib. There is a schedule that includes
recommendations for infant immunizations from the Advisory Committee on
Immunization Practices. Because infants put small objects in their mouths, choking is
a risk. Accidental deaths occur most commonly when infants share a bed with parents
(cosleeping) and are inadvertently wedged beneath another person, trapped in a
dangerous position, such as between the bed and the wall, or suffocated by bedding.
A)
This is normal, and this is how your child tries to exert control over his environment.
B)
This is unacceptable and you must provide appropriate discipline.
C)
This has to do with regression and is a response to stress.
D)
This is normal and has to do with learning right from wrong.
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28.
The nurse is visiting with the mother of a child age 20 months. The mother reports
concern about the frequency of the toddler’s loud outbursts of temper and saying no.
The nurse recalls Erikson’s theory about negativism and tells the
mother which of the following?
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Ans: A
Feedback:
Negativism (characteristically expressed by saying no) and outbursts of temper
result from the toddler’s efforts at control over the environment. Because this is
normal, severe discipline is not warranted. Regression, or behavior that is more
characteristic of a younger age, can occur at any time in response to stressful
circumstances. Learning right from wrong is one of the tasks in Havighurst’s theory.
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B)
Increasing in incidence in the United States
C)
Of significant concern to pediatricians
D)
Due to a lack of physical activity
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A benign and self-limiting disorder
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29.
The nurse is providing education on child growth and development to a group of
parents at a public health clinic. In answer to a question about childhood enuresis, the
nurse verifies that this can be a significant issue to the child and the
parents. The nurse should be sure to inform the group that this condition is which of the
following?
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Ans: A
Feedback:
Enuresis is diagnosed when a child is at least 5 years of age and is still having
involuntary urination, usually at night. Although this problem is significant to the
child and his or her parents, it is defined as a benign and self-limiting disorder,
usually ending between 6 and 8 years of age. There is no research indicating that the
incidence is increasing in the United States or that it is caused by lack of physical
activity.
30.
A)
The nurse is providing education on childhood safety to a group of parents. In response to a
question, the nurse relates
that the major causes of death in toddlers include which of the following? Choose all that
apply.
Infections
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Ans: A
Childhood diseases
C)
Drowning
D)
Motor vehicle crashes
E)
Accidents
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B)
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Accidents, such as motor vehicle crashes, poisonings, burns, drowning, choking and
aspirations, and falls are the major cause of death in toddlers. Childhood diseases are
not a factor due to current immunization protection. Most infections are treatable with
antibiotics.
A)
Respiratory difficulties
B)
Physiologic jaundice
C)
Caput succedaneum
D)
Subconjunctival hemorrhage
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31.
The nurse provides prenatal education to a group of pregnant teenagers. One of the
group members asks the nurse totalk about the possible complications for a newborn.
An accurate statement about neonatal complications would be which of
the following?
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Ans: A
Feedback:
Respiratory difficulties can occur and be life-threatening to the neonate. Birth
traumas that cause temporary symptoms are of concern because the parents need to
be reassured that the symptoms will disappear. Examples include caput succedaneum
(localized edema of the scalp), molding (elongation of the skull as the baby passes
through the birth canal), and subconjunctival hemorrhage. The nonthreatening nature
of physiologic jaundice, which commonly occurs in the neonate’s first days, should
also be explained to the parents.
A)
Has high lactose and low protein content
B)
Permanent immunity from certain infections
C)
Acidic environment which inhibits bacterial growth
D)
Contains antibodies, immunoglobulins, and leukocytes
E)
Alkaline environment which inhibits microbe growth
Ans: A, C, D
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32.
The nurse is providing prenatal education for a group of young pregnant women. One
woman asks about the advantages of breastfeeding her infant. Which of the following
would the nurse include in answer to this question? Choose all that
apply.
Feedback:
The neonate inherits a transient immunity from infections as a result of
immunoglobulins that cross the placenta. Breastfeeding provides further protection
against bacterial and viral infections through antibodies, immunoglobulins, and
leukocytes in breast milk. The high lactose content in breast milk, combined with
limited protein, promotes an acid environment that is unsuitable for bacterial growth.
33.
The nurse is educating a Young Childcare class and one of the parents asks what
kinds of actions on his part may increase safety for his 14-month-old daughter during
the next 2 years. Which of the following responses would be
appropriate? Choose all that apply.
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Ans: A
Keep medications locked away
B)
Keep plastic bags out of reach
C)
Use approved car seats
D)
Teach to chew small food well
E)
Do not swing by arms or legs
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Accidents are a leading cause of injuries and death in toddlers. Toddlers are curious
about medications and may swallow them if allowed. They may asphyxiate
themselves if allowed to play with plastic bags. Approved car seats will keep them
safe in case of a motor vehicle accident. Swinging by extremities may cause
dislocation of joints. Toddlers should not be allowed access to small-sized foods,
such as grapes, olives, or carrot rounds. Small, hard foods should never be allowed.
A)
Piaget
B)
Freud
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34.
A school nurse often observes adolescents challenging the decision making of their parents
and teachers. Which of these
developmental theorists relates this as an expected occurrence?
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C)
Havighurst
D)
Erikson
Ans: A
Feedback:
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According to Piaget, challenging the decision making of adults is common in adolescence.
A)
That is correct; you should go by how warm you are feeling.
B)
Always keep the baby bundled up to keep warm.
C)
The baby’s temperature responds quickly to the environmental temperature.
D)
If the baby shivers, add more layers of clothing.
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35.
A nurse is teaching the care of the newborn class and one of the members makes a
comment about keeping the baby too warm. She says, My mother always said to go
by how I feel; if I’m cold, the baby needs more clothing and if I’m too
warm, so is the baby.” Which of the following is the nurse’s best response?
Feedback:
The newborn is unable to regulate its body temperature, so it takes on the temperature
of the environment. The mother cannot go by how she feels because hormonal
changes after childbirth may affect her temperature. Always keeping the baby bundled
will probably cause overheating in some cases. The newborn is unable to produce heat
by shivering.
Chapter 24, Middle and Older Adulthood
1.
A client age 71 years has recently integrated large amounts of blueberry and
pomegranate juice into her diet, touting their antioxidant properties that mitigate the
effects of separated high-energy electrons. The client’s actions reflect which
of the following theories of aging?
A)
Free radical theory
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B)
Genetic theory
C)
Cross-linkage theory
D)
Immunity theory
Ans: A
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Free radicals, formed during cellular metabolism, are molecules with separated highenergy electrons, which can have adverse effects on adjacent molecules.
Antioxidants are purported to mitigate the effects of these free radicals. Neither the
genetic theory, immunity theory, nor cross-linkage theory of aging directly addresses
the potentially harmful effects of free radicals.
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The staff at a long-term care facility have made minimal effort to secure a shared
room for a couple in their late 80s, who have been married for several decades. The
manager states, “I’m sure that bedroom activity is the last thing on their
mind these days.” How should the nurse best respond to the manager’s characterization of
sexuality in olderadults?
“They might not be as active as in years past, but sexuality is still important for older people.”
B)
“It’s actually a myth that older adults have sex less often than younger adults.”
C)
“There’s no reason that we should assume they’re less interested than when they first got
married.”
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A)
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D)
“Their sexual activity has probably stopped by now, but they still need companionship.”
Ans: A
Feedback:
Although sexual activity may be less frequent, the ability to perform and enjoy sexual
activity lasts well into the 90s in healthy older adults. However, it is unlikely that
interest remains at the same level as when the couple was first married.
A)
The client is oriented to person and place but is unsure of the month.
B)
The client states that his urine stream is less strong than in the past.
C)
The client claims to hear high-pitched sounds less clearly than earlier in life.
D)
The client’s gait is slow and his posture appears stooped.
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3.
Which of the following assessment findings of a male client age 77 years should signal the
nurse to a potentially
pathologic finding, rather than a normal age-related change?
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Ans: A
Feedback:
Age-related physiologic changes include a weakening of bladder emptying,
presbycusis, and a slow gait that may be accompanied by stooped posture.
Disorientation to time, however, should always prompt the nurse to perform further
assessment and should never be considered a normal accompaniment to the aging
process.
4.
A)
A home health care nurse has observed that a client 80 years of age, who has multiple
chronic health problems, takes a total of 19 medications on either a scheduled or PRN
(as needed) basis. How should the nurse address this client’s risk
of harm from polypharmacy?
Ensure that the client’s care is coordinated and encourage the primary care provider to review
her medication regimen.
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B)
Recommend holistic and herbal remedies to replace some of the medications.
C)
Contact the client’s local pharmacy to discuss possible changes to her medication regimen.
D)
Encourage the client to reduce her medication load by withholding some medications when
she is asymptomatic.
Ans: A
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Polypharmacy can sometimes be addressed by conducting a thorough and
coordinated review of a client’s medication regimen. It would be inappropriate and
unsafe for the nurse to arbitrarily withhold some medications or to encourage the
client to do so. The client’s local pharmacist is not normally able to make
independent changes to the client’s medication regimen.
According to the free radical theory of aging, what substance is affected by aging and causes
damage?
A)
Carbohydrates
B)
Proteins
C)
Water
D)
Lipids
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Ans: D
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Free radicals, formed during cellular metabolism, have adverse effects on adjacent
molecules. Lipids (found in cell membranes, proteins, and cell organelles) are
affected. Over time, irreversible damage results from the accumulated effects of this
damage. Carbohydrates, proteins, and water are not affected in this way.
Which aging theory describes a chemical reaction that produces damage to the DNA and cell
death?
A)
Genetic theory
B)
Immunity theory
C)
Cross-linkage theory
D)
Free radical theory
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Cross-linkage is a chemical reaction that produces damage to the DNA and cell
death. As one ages, cross-links accumulate, leading to essential molecules in the cell
that bind together and interfere with normal cell function.
7.
According to Erikson, the middle adult is in a period of generativity versus stagnation. What
happens if developmental
tasks are not achieved?
A)
Physical changes are denied
B)
Health needs become a major concern
C)
Motivation to learn is decreased
D)
Awareness of own mortality increases
Ans: B
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Feedback:
According to Erikson, if the middle adult does not achieve the tasks of generativity,
stagnation results. Adults who do not achieve the tasks of establishing and guiding
the next generation, accepting middle-age changes, adjusting to the needs of aging
parents, and re-evaluating goals and accomplishments tend to focus on themselves
and become overly concerned with their own physical and emotional health needs.
A)
Midlife transition
B)
Support of the rights of others
C)
Fear for the future
D)
Trust in spiritual strength
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8.
A middle adult client requests visits by the hospital chaplain and reads the Bible each day
while hospitalized for
treatment of heart problems. What is the individual illustrating?
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The middle adult, according to Fowler’s theory of spiritual development, is less rigid
in his or her beliefs and has increased faith in a supreme being, as well as trust in
spiritual strength.
9.
While conducting a health assessment with an older adult, the nurse notices it takes the person
longer to answer
questions than is usual with younger clients. What should the nurse do?
A)
Stop asking questions so as not to confuse the client.
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B)
Slow the pace and allow extra time for answers.
C)
Realize that the client has some dementia.
D)
Ask a family member to answer the questions.
Ans: B
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Cognition does not change appreciably with aging. It is normal for the older adult to
take longer to respond and react. The nurse should slow the pace of care and allow
older clients extra time to answer questions or complete activities.
A)
Explain why he or she has certain emotions
B)
Become more introspective and self-focused
C)
Practice life review or reminiscence
D)
Look backward with regret for undone tasks
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10.
A nurse says to an older adult who is being cared for at home, “Tell me what your life was like
when you were first
married.” What does this statement encourage the client to do?
Ans: C
Feedback:
Older adults search for emotional integration and acceptance of the past and present.
They often like to tell stories of past events in life to reminisce, and to restructure life
experiences to facilitate achieving ego integrity. This phenomenon, called life review
or reminiscence, has been identified worldwide. In a sense, this is a way for an older
adult torelive
and restructure life experiences and is part of achieving ego integrity. Nurses can also
use reminiscence as a therapy to facilitate adaptation to present circumstances.
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A)
Social isolation
B)
Social ineptness
C)
Ineffective coping
D)
Negativism of aging
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11.
An older adult, newly widowed, has been unable to adjust to her change in roles or form new
relationships. What is this
experience called?
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Ans: A
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If an older adult cannot adjust to changes in social roles and form new relationships,
social isolation can become a problem. Social isolation is a sense of being alone and
lonely as a result of having fewer meaningful relationships. Social isolation is a
sense of being alone and lonely as a result of having fewer meaningful relationships.
It may occur because of declining health or income, transportation problems, or
ageism. Whatever the cause, prolonged social isolation has been associated with
declining health and higher mortality rates.
What is one reason for the “middle-aged spread” often seen in middle adults?
A)
Changes in hormones
B)
Loss of satisfactory roles
C)
Decreased physical activity
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D)
Satisfaction with one’s life
Ans: C
Feedback:
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Middle-aged adults tend to maintain previous eating patterns and caloric intake while
being less physically active. This trend can result in obesity and atherosclerosis,
increasing the risk for high blood pressure, coronary artery disease, renal failure, and
diabetes.
A)
Cardiovascular disease, cancer
B)
Upper respiratory infections, fractures
C)
Communicable diseases, dementia
D)
Sexually transmitted diseases, drug abuse
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13.
A nurse educates adults in preventive measures to avoid problems of middle adult years.
Which of the following are the
major health problems during the middle adult years?
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Ans: A
Feedback:
The major health problems of the middle adult years are cardiovascular and
pulmonary diseases, cancer, rheumatoid arthritis, diabetes, obesity, alcoholism, and
depression. The risk for these health problems often depends on a combination of
lifestyle factors and aging.
14.
Which of the following statements is true for nursing care of older adults?
A)
Most older adults are unable to care for themselves independently.
B)
Most older adults are functional, benefiting from health-oriented interventions.
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C)
Fewer older adults will require nursing care during the 21st century.
D)
Interventions for older adults are no different from those for young adults.
Ans: B
Feedback:
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As the number of older adults increases, nurses will spend more time providing care
for this population. Most older adults are not impaired but remain functional in the
community, thereby benefiting from health-oriented nursing interventions.
A)
Family members do not need to be as involved in the care of the older adult.
B)
Almost 100% of all older adults have limitations from multiple chronic illnesses.
C)
Older adults do not want to maintain their health and independence.
D)
Medications, hospitalizations, and medical supplies increase economic difficulties.
Ans: D
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15.
A nurse is developing a plan of care for an older adult with chronic heart disease. Which of the
following factors must
be considered?
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Family members must learn to cope with needs of the chronically ill older adult.
About 50% of older adults have limitations from one or more chronic illnesses. Most
older adults want to remain healthy and independent. Economic difficulties are a
major concern.
A)
Risk for decreased social interaction
B)
Altered consciousness
C)
Risk for accidental injury
D)
Risk for impaired judgment
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16.
A woman aged 88 years who lives alone has deficits in vision and hearing, although
these deficits are corrected by glasses and hearing aids. Her blood pressure medicine
is making her dizzy. What response to these health problems
would the home health nurse identify?
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Ans: C
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The older adult is at increased risk for accidental injury because of changes in vision
and hearing, loss of muscle mass and strength, slower reflexes and reaction time, and
decreased sensory ability. The effects of chronic illness and medications may also
make the older adult more prone to accidents.
17.
The daughter of an older adult calls the nurse practitioner to report that her mother is
becoming very confused after dark.
What is this type of confusion named?
A)
Night-time confusion
B)
Sundowning syndrome
C)
Alzheimer’s disease
D)
Cognitive dysfunction
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Ans: B
Feedback:
Sometimes confusion and depression in an older adult are mistaken for true
dementia. A type of confusion called sundowning syndrome sometimes occurs, in
which the older adult habitually becomes confused after dark.
A)
Reproductive
B)
Cardiovascular
C)
Respiratory
D)
Cranial nerves
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18.
During a health assessment, a woman age 49 years tells the nurse that she is “just so
tired and has been having mood swings and hot flashes.” Based on this information,
the nurse would conduct a more thorough history and assessment of
what body system?
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Ans: A
Women between the ages of 40 and 55 experience menopause, with a gradual
decrease in ovarian function and subsequent depletion of estrogen and progesterone.
Menstrual periods stop abruptly or gradually, and many women experience hot
flashes, mood swings, and fatigue. The nurse would focus on assessing the
reproductive system.
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A)
These are normal physiologic changes of aging.
B)
The observations are not typically found in older adults.
C)
These are abnormal observations and must be reported.
D)
Extra education will be necessary to prevent complications.
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19.
While caring for an older adult male, the nurse observes that his skin is dry and wrinkled, his
hair is gray, and he needs
glasses to read. Based on these observations, what would the nurse conclude?
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Dry wrinkled skin, gray hair, and needing glasses to read are all commonly occurring
and normal physiologic changes of aging. They are not abnormal and do not lead to
complications.
A)
Racism
B)
Ageism
C)
Indifference
D)
Knowledge
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20.
A teenager states, “Old people are different. They don’t need the same things that young
people do.” What is this
statement an example of?
Ans: B
Feedback:
Ageism is a form of prejudice, like racism, in that older adults are stereotyped by
characteristics found in only a few members of their age group. In ageism, older
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adults are viewed as different and without the same desires, needs, and concerns as
others.
Which of the following statements is true of the older adult population?
A)
Old age begins at 65 years of age.
B)
Most older adults live in nursing homes.
C)
Older adults are not interested in sex.
D)
Incontinence is not a part of aging.
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Although a common myth of aging is that bladder problems are common, in actuality
incontinence is not a normal part of aging and should warrant medical attention.
A)
“I will make exercise a part of my daily activities.”
B)
“I should eat a diet high in fats but low in fiber.”
C)
“I will begin a smoking cessation program this week.”
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22.
A nurse is educating a group of middle adults about health promotion. What statement by one
of the participants
indicates the need for additional education?
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D)
“I only have one glass of wine a day with dinner.”
Ans: B
Feedback:
Health promotion activities for the middle adult include a diet low in fat and
cholesterol that includes fruits, vegetables, and fiber; regular daily exercise; drinking
alcohol in moderation; and no smoking.
In general, what is the focus of care for nurses who work with older adults?
A)
Providing all necessary physical care
B)
Referring clients for needed emotional support
C)
Establishing goals and expected outcomes for the client
D)
Assisting clients to function as independently as possible
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23.
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Ans: D
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The focus of nursing care is to assist older adults to function as independently as
possible, and to support their individual strengths.
24.
A nurse is providing care to an older adult at home after major abdominal surgery. Which of
the following nursing
diagnoses would most likely be appropriate?
A)
Adult Failure to Thrive
B)
Anticipatory Grieving
C)
Impaired Memory
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D)
Risk for Infection
Ans: D
Feedback:
The older adult heals more slowly and may have decreased immune function.
Combined with dry skin that has decreased elasticity, these factors increase the risk
for infection from the abdominal incision.
A)
Risk for falls
B)
Risk for imbalanced body temperature
C)
Risk for infection
D)
Risk for sedentary lifestyle
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25.
A nurse documents the following assessment on an older adult client’s chart: “dry, thin skin.”
Which of the following
nursing diagnoses would be appropriate for this client?
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Ans: C
Feedback:
The dry, thin skin of elderly clients is prone to infection.
26.
An older adult lives in a facility that provides, housing, group meals, personal care and
support, social activities, and
minimal health care services. What type of facility does this describe?
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A)
Nursing home
B)
Assisted living
C)
Accessory apartment
D)
Home modification
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Various types of housing options exist for older adults. Assisted-living facilities
generally provide housing, group meals, personal care and support services, and
social activities in a social setting, and there may be some health care provided.
Nursing homes provide skilled nursing care and/or long-term care, including meals,
personal care, and medical care. An accessory apartment is a separate apartment
constructed in part of an existing house, such as a basement or attic. Home
modification allows older adults to stay in their own homes by making changes to the
home.
A)
Encourage frequent naps in order to ensure adequate sleep and rest.
B)
Encourage residents to take dietary supplements when safe.
C)
Conduct activities at a slower pace and allow residents time to respond.
D)
Encourage residents to engage in the present rather than perform reminiscence.
E)
Promote self-care and only assist residents when it is necessary.
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27.
A nurse who provides care in a long-term care facility recognizes the need to promote
health rather than solely treating illness. Which of the following measures should the
nurse encourage among the older adult resident population of the
facility? Select all that apply.
Ans: B, C, E
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Dietary supplements are appropriate and conducive to health, provided safety has
been considered. It is appropriate to conduct activities at a somewhat slower pace
with older adults, since a mild slowing of cognitive and neurological function is a
recognized phenomenon that is considered normal. Self-care should be fostered and
assistance provided when necessary. Frequent naps are counterproductive to healthy
sleeping and waking cycles. Reminiscence is a healthy and important process and it
does not preclude engagement with the present.
Which of the following are physical changes that occur in middle adulthood? Select all that
apply.
A)
Body fat is redistributed.
B)
The skin is more elastic.
C)
Cardiac output begins to increase.
D)
Muscle mass gradually decreases.
E)
There is a loss of calcium from bones.
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In middle adulthood, fatty tissue is redistributed; men tend to develop abdominal fat,
women thicken through the middle, and the skin is drier. Also, cardiac output begins
to decrease; muscle mass, strength, and agility gradually decrease; there is a loss of
calcium from bones, especially in perimenopausal women; and hormone production
decreases, resulting in menopause or andropause.
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A)
Ask a family member to stay with him.
B)
Cover him with a blanket for warmth.
C)
Reattach the restraints.
D)
Put side rails up before leaving the client.
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29.
While providing hygiene care to a confused older adult client diagnosed with Alzheimer’s
disease, the nures is called to
the nursing station. To ensure patient safety the nurse must do what?
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The issue is safety of a confused client, so the side rails must be up. It is not the
family’s responsibility to maintain his safety, a blanket is not for safety, and restraints
are not routinely used.
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30.
The nurse is assigned to a 52-year-old male patient. He is talkative and usually
friendly when the nurse enters his room. Today, however, he is standing at the mirror
and says: I lost my job because the company downsized, there isn’t
anything I can do. As his caregiver, the nurse recognizes this expression of concern is related
to which of the following?
A)
He assumes the termination is his fault.
B)
Dissatisfaction with changes in his appearance and energy levels.
C)
His career goals and retirement plans are compromised.
D)
He is in an androgenic crisis.
Ans: C
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The loss of his employment is a major change that disrupts his life-long goals. The
middle adult is becoming aware of physical changes and limited time to live. This
situation is not a hormonal crisis, and although the patient may feel the job loss is his
fault, that is not what he expressed.
A)
a behavior change at sunset as the client becomes more fatigued, listless, and disoriented.
B)
occasional onset of marked confusion, wandering and feeling lost during the afternoon, before
sunset.
C)
habitual agitation, restlessness, and confusion that occurs after dark.
D)
increasing sleeplessness at night because the patient cat-naps during the day.
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31.
Dementia is a disorder that progresses over several years, with increasing confusion,
forgetting family, and disorientation in familiar surroundings. A common problem
with dementia patients is sundowning syndrome, which is
described as …
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Ans: C
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Sundowning syndrome is described as a common problem in clients with dementia, in
which the older adult client habitually becomes confused, restless, and agitated after
dark.
32.
Eighty percent of older adults have one chronic illness, and 60% have at least two. The older
adult’s ability to adapt
determines:
A)
whether they are ill or healthy.
B)
degree of loss of the physiologic reserve of the various organ systems
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C)
that not wanting to change makes them more determined.
D)
how quickly they become overwhelmed with the stress of it all.
Ans: A
Feedback:
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There is growing evidence that aging is not synonymous with loss of function or
disability. Although coping with chronic illness is common for the older adult, the
ability to adapt determines whether they are ill or healthy.
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33.
One of the adverse events that Medicare will no longer reimburse the hospital for is an inhospital fall. Fall prevention is
a major part of nursing and risk management. In order to reduce the risk of falling, the nurse
must:
ensure that the patient wears his prescription glasses when up.
B)
post signs to alert staff to the patient at high risk for falls.
C)
always assist every patient with ambulation.
D)
assess the patient’s fatigue level.
E)
monitor gait and balance.
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A)
Ans: A, B, D, E
Feedback:
Fall prevention need only apply to patients at risk. It is not realistic to expect that
every patient would always need assistance to ambulate.
34.
The home health nurse is making an initial home visit to a male widow age 76 years.
During the assessment the nurse finds that the client is taking multiple medications.
The client states that he has also been taking some herbal remedies.
What should the nurse be sure to include in the client education?
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A)
Herbal remedies are holistic.
B)
Herbal remedies are often cheaper than prescribed medicine.
C)
The importance of avoiding herbal remedies
D)
The need to inform his physician and pharmacist about the herbal remedies
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Ans: D
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Herbal remedies combined with prescribed medications can lead to interactions that
may be toxic. Clients should notify the physician and pharmacist of any herbal
remedies they are using. Option A is incorrect even though herbal remedies are
considered holistic; this is not something that is necessary to include in the client
education. Option B is incorrect; herbal remedies may be cheaper than prescribed
medicine but this is still not something that is necessary to include in the client
education. Option C is incorrect because for most people it is not necessary to avoid
herbal remedies.
According to Havighurst, which of the following are developmental tasks of middle
adulthood? Select all that apply.
A)
Accept and adjust to physical changes.
B)
Maintain a satisfactory occupation.
C)
Assist children to become responsible adults.
D)
Maintain social contacts and relationships.
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E)
Relate to one’s spouse or partner as a person.
Ans: A, B, C, E
Feedback:
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The developmental tasks of the middle adult described by Havighurst (1972) are
learned behaviors arising from maturation, personal motives and values, and civic
responsibility. To successfully master this developmental stage, the middle adult must
accept and adjust to physical changes, maintain a satisfactory occupation, assist
children to become responsible adults, adjust to aging parents, and relate to one’s
spouse or partner as a person. Maintaining social contacts and relationships, as well
as being flexible and adapting to age-related roles, is a task of older adulthood.
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Chapter 25, Asepsis and Infection Control
A)
Prodromal stage
B)
Incubation period
C)
Full stage of illness
D)
Convalescent period
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1.
The nurse is aware that an antiviral medication is most effective when given during which
phase of the infectious
process?
Feedback:
When given during the prodromal stage of certain viruses, antiviral medications can shorten
the full stage of the illness.
2.
Which of the following most accurately defines an infection?
A)
An illness resulting from living in an unclean environment
B)
The result of lack of knowledge about food preparation
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C)
A disease resulting from pathogens in or on the body
D)
An acute or chronic illness resulting from traumatic injury
Ans: C
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An infection is a disease state that results from the presence of pathogens (diseaseproducing microorganisms) in or on the body.
A)
Virus
B)
Bacteria
C)
Fungi
D)
Spores
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3.
A client who has had abdominal surgery develops an infection in the wound while still
hospitalized. Which of the
following agents is most likely the cause of the infection?
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Some of the more prevalent agents that cause infection are bacteria, viruses, and
fungi. Bacteria are the most significant and most commonly observed infectioncausing agents in health care institutions.
A)
Other people
B)
Food
C)
Soil
D)
Animals
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4.
A nurse caring for a client who has gas gangrene knows that this infection originated in which
of the following
reservoirs?
Ans: C
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The soil can act as a reservoir; the organisms that cause gas gangrene and tetanus are
examples of pathogens whose reservoir is soil. Nurses can serve as reservoirs and
inadvertently transfer pathogenic organisms to clients. For example, a nurse with
artificial nails may harbor a large number and variety of microbes under the nails.
Undercooked ground beef, tomatoes, and bagged spinach are reservoirs that have
been identified as responsible for recent outbreaks of E. coli infections. The rabies
virus is an example of a pathogen whose reservoir is various animals, notably dogs,
squirrels, bats, and raccoons.
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5.
A client with an upper respiratory infection (common cold) tells the nurse, “I am so angry with
the nurse practitioner
because he would not give me any antibiotics.” What would be the most accurate response by
the nurse?
“Antibiotics have no effect on viruses.”
B)
“Let me talk to him and see what we can do.”
C)
“Why do you think you need an antibiotic?”
D)
“I know what you mean; you need an antibiotic.”
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A)
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Viruses are the smallest of all microorganisms. Viruses, including the common cold
and AIDS, cause many infections. Antibiotics have no effect on viruses.
6.
A woman tests positive for the human immunodeficiency virus antibody but has no symptoms.
She is considered a
carrier. What component of the infection cycle does the woman illustrate?
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A)
A reservoir
B)
An infectious agent
C)
A portal of exit
D)
A portal of entry
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Humans may act as reservoirs for an infectious agent and not exhibit any
manifestations of the disease. They are considered carriers and can transmit the
disease. In this case, the woman is the reservoir for the HIV virus.
A)
Direct contact
B)
Indirect contact
C)
Vectors
D)
Airborne route
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7.
A man on an airplane is sitting by a woman who is coughing and sneezing. If she has an
infection, what is the most
likely means of transmission from the woman to the man?
Ans: D
Feedback:
An organism may be transmitted from its reservoir by various means or routes.
Microorganisms can be spread through the airborne route when an infected host
coughs, sneezes, or talks or when the organism becomes attached to dust particles.
A nurse is caring for an adolescent who is diagnosed with mononucleosis, commonly called
“the kissing disease.” The
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nurse explains that the organisms causing this disease were transmitted by:
A)
direct contact.
B)
indirect contact.
C)
airborne route.
D)
vectors.
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Ans: A
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Organisms can enter the body by way of the contact route, either directly or indirectly.
Direct contact involves proximity between the susceptible host and an infected person
or a carrier, such as through touching, kissing, or sexual intercourse. Mononucleosis
can be spread through direct contact with saliva, mucus from the nose and throat, and
sometimes tears.
Of all possible nursing interventions to break the chain of infection, which is the most
effective?
A)
Administering medications
B)
Providing good skin care
C)
Practicing hand hygiene
D)
Wearing gloves at all times
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Ans: C
Feedback:
Practicing hand hygiene is the most effective way to help prevent the spread of
organisms. Nurses need to focus on this simple procedure that can interrupt the cycle
of infection.
A)
Direct contact
B)
Indirect contact
C)
Airborne route
D)
Vectors
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10.
A nurse is educating a rural community group on how to avoid contracting West Nile
virus by using approved insect repellant and wearing proper coverings when
outdoors. By what means is the pathogen involved in West Nile virus
transmitted?
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Ans: D
Vectors, such as mosquitoes, ticks, and lice, are nonhuman carriers that transmit
organisms from one host to another, that is, by injecting salivary fluid when a human
bite occurs.
11.
Which of the following questions asked by the nurse when taking a client’s health history
would collect data about
infection control?
A)
Tell me what you eat in each 24-hour period.
B)
Do you sleep well and wake up feeling healthy?
C)
What were the causes of death for your family members?
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D)
When did you complete your immunizations?
Ans: D
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The nurse’s role in infection control includes early detection and surveillance. When
taking a health history, the nurse asks about immunization status and
previous/recurring infections. The other questions are appropriate in a health history,
but are not specific to infections.
A college-aged student has influenza. At what stage of the infection is the student most
infectious?
A)
Incubation period
B)
Prodromal stage
C)
Full stage of illness
D)
Convalescent period
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12.
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A person is most infectious during the prodromal stage. Early signs and symptoms of
disease are present, but these are often vague and nonspecific. During this phase, the
person often does not realize that he or she is contagious. As a result, the infection
spreads.
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Which of the following is an example of the body’s defense against infection?
A)
Racial characteristics
B)
Body shape and size
C)
Immune response
D)
Level of susceptibility
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Ans: C
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The body has various defenses against infection, including normal flora and the
inflammatory response. One of the most effective is the immune response, which
involves specific reactions in the body as it responds to an invading foreign protein,
such as bacteria. The foreign material is called an antigen, and the body commonly
responds by producing an antibody. Race, body size and shape, and level of
susceptibility do not affect defense against infection.
A)
An older adult with several chronic illnesses
B)
An infant who has just received first immunizations
C)
An adolescent who had a basketball physical
D)
A middle-aged adult with joint pain and stiffness
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14.
A nurse has seen several clients at a community health center. Which of the clients would be
most at risk for developing
an infection?
Ans: A
Feedback:
Many factors affect the risk for infection, including age, sex, race, and heredity.
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Neonates and older adults, especially those who have preexisting illnesses, appear to
be more vulnerable to infection.
A)
Stress may adversely affect normal defense mechanisms.
B)
White blood cells provide resistance to certain pathogens.
C)
Intact skin and mucous membranes protect against microbial invasion.
D)
Age, race, sex, and hereditary factors influence susceptibility to infection.
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15.
A client comes to the emergency department with major burns over 40% of his body.
Although all of the following are
true, which one would provide the rationale for a nursing diagnosis of Risk for Infection?
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Intact skin and mucous membranes provide resistance to certain pathogens. A major
burn of 40% of the body provides multiple portals of entry for pathogens.
A)
“I will wash my hands before and after going to the bathroom.”
B)
“I don’t wear a condom when I have sex, but I know my partners.”
C)
“I always eat fruits and vegetables, and I sleep eight hours a night.”
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16.
A nurse is educating adolescents on how to prevent infections. What statement by one of the
adolescents indicates that
more education is needed?
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D)
“When I have an infection, I rest and take my medications.”
Ans: B
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Sensible nutrition, adequate rest and exercise, and good personal hygiene habits can
help maintain optimum body function and immune response. Unsafe sex practices are
potentially dangerous and provide an opportunity for pathogens to enter a host and
cause an infection.
A)
Nosocomial
B)
Viral
C)
Iatrogenic
D)
Antimicrobial
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17.
A female client is on isolation because she acquired a methicillin-resistant S. aureus (MRSA)
infection after
hospitalization for hip replacement surgery. What name is given to this type of infection?
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For various reasons and sometimes despite best efforts, certain clients in health
agencies develop infections that were not noted to be present on admission. The term
nosocomial infection is used to describe a hospital-acquired infection.
18.
The following procedures have been ordered and implemented for a hospitalized client. Which
procedure carries the
greatest risk for a nosocomial infection?
A)
Enema
B)
Intramuscular injections
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C)
Heat lamp
D)
Urinary catheterization
Ans: D
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Most nosocomial infections are caused by bacteria. Urinary tract infections,
pneumonia, and bloodstream infections are the three most common nosocomial
infections, most of which can be traced to an invasive device (e.g., a urinary
catheter).
A)
Mandating antibiotics for all nursing home residents
B)
Have written, infection-prevention practices for all employees
C)
Requiring all employees to have monthly screenings for skin flora
D)
Restricting visitors and community activities for residents
Ans: B
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19.
A nursing home recently has had a significant number of nosocomial infections. Which of the
following measures might
be instituted to decrease this trend?
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Health care agencies, including hospitals and nursing homes, have found several
measures to be successful in reducing the incidence of nosocomial infections. One of
these measures is having written, infection-prevention practices for all personnel.
Adherence to hand hygiene recommendations and infection-control precaution
techniques can prevent many nosocomial infections.
What are the recommended cleansing agents for hand hygiene in any setting when the risk of
infection is high?
A)
Liquid or bar hand soap
B)
Cold water
C)
Hot water
D)
Antimicrobial products
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Using handwashing products that contain an antimicrobial or antibacterial
ingredient is recommended in anysetting where the risk of infection is high. When
present in certain concentrations, these agents can kill bacteria orsuppress their
growth.
21.
A nurse has completed morning care for a client. There is no visible soiling on her hands.
What type of technique is
recommended by the CDC for hand hygiene?
A)
Do not wash hands, apply clean gloves.
B)
Wash hands with soap and water.
C)
Clean hands with an alcohol-based handrub.
D)
Wash hands with soap and water, follow with handrub.
Ans: C
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Feedback:
The CDC recommends that a health care worker whose hands are visibly soiled or
contaminated with blood or body fluids wash the hands with soap and water. If the
hands are not visibly soiled, an alcohol-based handrub can be used.
Which statement is true of health care personnel and good hand hygiene?
A)
Hand hygiene is carefully followed.
B)
Compliance is difficult to achieve.
C)
Only nurses need to practice hand hygiene.
D)
Wearing gloves reduces the need for hand hygiene.
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Even though health care personnel know the importance of good hand hygiene, most
studies report that compliance with this simple preventive measure is difficult to
achieve. Despite intensive educational efforts, good hand hygiene is practiced
infrequently.
23.
A nurse is caring for a client with a serious bacterial infection. The client is dehydrated.
Knowledge of the physical
effects of the infection would support which of the following nursing diagnoses?
A)
High Risk for Infection
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B)
Excess Fluid Volume
C)
Risk for Imbalanced Body Temperature
D)
Risk for Latex Allergy Response
Ans: C
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The response of the body to an infectious process (fever), as well as dehydration,
would support the nursing diagnosis of Risk for Imbalanced Body Temperature for
this client.
What is the correct rationale for using body substance precautions?
A)
The risk of transmitting HIV in sputum and urine is nonexistent.
B)
Disease-specific isolation procedures are adequate protection.
C)
Only actively infected clients are considered contagious.
D)
All body substances are considered potentially infectious.
Ans: D
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24.
Feedback:
Body substance precautions are an extension of universal precautions. These
precautions consider all body substances potentially infectious, regardless of a
person’s diagnosis. The consistent use of barriers whenever health care personnel
have contact with moist body substances, mucous membranes, and nonintact skin is
highly recommended.
25.
The latest CDC guidelines designate standard precautions for all substances except which of
the following?
A)
Urine
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B)
Blood
C)
Sweat
D)
Vomitus
Ans: C
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Current CDC guidelines define standard precautions as those used in the care of all
hospitalized individuals, regardless of their diagnosis or possible infection status.
They apply to blood, all body secretions and excretions (except sweat), nonintact
skin, and mucous membranes.
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A student nurse is performing a urinary catheterization for the first time and inadvertently
contaminates the catheter by
touching the bed linens. What should the nurse do to maintain surgical asepsis for this
procedure?
Nothing, because the client is on antibiotics.
B)
Complete the procedure and then report what happened.
C)
Apologize to the client and complete the procedure.
D)
Gather new sterile supplies and start over.
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A)
Ans: D
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When following surgical asepsis, areas are considered contaminated if they are
touched by any object that is also not sterile. One of the most important aspects of
medical and surgical asepsis is that the effectiveness of both depends on faithful and
conscientious practice by those carrying them out.
A)
With sterile forceps or hands wearing sterile gloves
B)
By carefully handling them with clean hands
C)
With clean forceps that touch only the outermost part of the item
D)
By clean hands wearing clean latex gloves
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27.
A nurse is performing a sterile dressing change. If new sterile items or supplies are needed,
how can they be added to the
sterile field?
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Once a sterile field is established, objects on a field may only be handled by using
sterile forceps or with hands wearing sterile gloves. The other choices would
contaminate the sterile field.
28.
A nurse is positioning a sterile drape to extend the working area when performing a urinary
catheterization. Which of the
following is an appropriate technique for this procedure?
A)
Use sterile gloves to handle the entire drape surface.
B)
Fold the lower edges of the drape over the sterile-gloved hands.
C)
Touch only the outer two inches of the drape when not wearing sterile gloves.
D)
When reaching over the drape do not allow clothing to touch the drape.
Ans: A
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Feedback:
Using sterile gloves allows the nurse to handle the entire drape surface. The nurse
should fold the lower edges of the drape over the sterile-gloved hands for protection
when positioning. When not wearing sterile gloves, the nurse should touch only the
outer one inch (2.5 cm) of the drape, and the nurse should not reach over the drape
because this would contaminate a sterile area.
A)
Avoid physical contact with the infected client.
B)
Avoid jewelry with prongs or protruding stones.
C)
Isolate the client and keep the room door closed.
D)
Shake linens properly when changing the beds.
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29.
What are the general nursing care guidelines that the nurse should follow when caring for
clients in a health care
facility?
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Ans: B
The nurse should avoid wearing artificial nails, colored nail polish, and jewelry with
prongs or protruding stones to avoid the spread of pathogens. The nurse should
avoid physical contact with the infected client only when the disease is known to be
transmitted through physical contact. The nurse can practice isolation of the client if
instructed by the physician, but need not keep the room door closed. The nurse
should avoid shaking linens when changing the beds because this causes spread of
dust and pathogens.
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Wash hands with alcohol-based hand wash.
B)
Wear a pair of sterile latex gloves.
C)
Use sterilizing acid to clean the injury.
D)
Use sterile solutions such as normal saline.
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30.
A nurse is required to clean the open wounds of a client who has been involved in an
automobile accident. What
intervention would the nurse need to perform when cleaning open wounds to protect himself
from infection?
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In order to protect themselves from infections when dealing with open wounds,
nurses should wear sterile latex gloves when cleaning the open wounds of a client.
Latex gloves allow the nurse to handle sterile equipment and supplies without
contaminating them during the treatment, and the gloves also protect the nurse from
the infection caused by the injury. Though washing hands with an alcohol-based
hand wash helps kill the microorganisms, it will not protect the nurse from being
infected during the cleaning of the wound. Sterilizing acid is used to sterilize heatsensitive instruments. Sterilizing solutions such as normal saline are used to avoid
contamination.
31.
A nurse is changing the bed linen of a client admitted to the health care facility. Which of the
following isolation
precautions should the nurse follow?
A)
Standard precautions
B)
Droplet precautions
C)
Contact precautions
D)
Airborne precautions
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Ans: A
Feedback:
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Health care personnel follow standard precautions whenever there is the potential for
contact with the following: blood; body fluids except sweat, regardless of whether
they contain visible blood; non-intact skin; and mucous membranes.
Standard precautions are measures for reducing the risk of microorganism
transmission from both recognized and unrecognized sources of infection. The other
three precautions are transmission-based precautions, which are measures for
controlling the spread of infectious agents from clients known to be, or suspected of
being, infected with highly transmissible or epidemiologically important pathogens.
Which of the following are characteristics of the stage of infection known as full stage of
illness? Select all that apply.
A)
It is the interval between the pathogen’s invasion of the body and the appearance of symptoms
of infection.
B)
Specific signs and symptoms are present.
C)
The organisms are growing and multiplying.
D)
The signs and symptoms disappear, and the person returns to a healthy state.
E)
Early signs and symptoms of disease are present, but these are often vague and nonspecific.
Ans: B, C
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32.
Feedback:
The incubation period is the interval between the pathogen’s invasion of the body and
the appearance of symptoms of infection. During this stage, the organisms are
growing and multiplying. The presence of specific signs and symptoms indicates the
full stage of illness, and the type of infection determines the length of the illness and
the severity of the
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manifestations. The convalescent period is the recovery period from the infection;
the signs and symptoms disappear, and the person returns to a healthy state. A person
is most infectious during the prodromal stage, in which early signs and symptoms of
disease are present, but are often vague and nonspecific (ranging from fatigue and
malaise to a low- grade fever).
Which of the following statements about glove use and hand hygiene is true?
A)
Artificial fingernails should not be worn by staff involved in direct client care.
B)
Nonsterile gloves can be decontaminated with alcohol-based hand rub, but must be changed
between clients.
C)
Use of alcohol-based hand rubs is appropriate after using the restroom.
D)
The use of sterile gloves reduces the need for hand hygiene.
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The CDC Guideline for Hand Hygiene in Health-Care Settings (2002) specifies that
health care personnel involved in patient care should not wear artificial nails because
they are more likely to be associated with higher bacterial counts.
34.
An experienced nurse is teaching a student nurse the proper use of hand hygiene. Which of the
following is an accurate
guideline that should be discussed?
A)
The use of gloves eliminates the need for hand hygiene.
B)
The use of hand hygiene eliminates the need for gloves.
C)
Hand hygiene must be performed after contact with inanimate objects near the client.
D)
Hand lotions should not be used after hand hygiene.
Ans: C
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Feedback:
Hand hygiene must be performed when moving from a contaminated body site to a
clean body site during client care, and after contact with inanimate objects near the
client. Using gloves does not eliminate the need for hand hygiene and, in some cases,
gloves must still be used after hand hygiene. Lotions may be used to prevent
irritation.
A)
20 seconds
B)
30 seconds
C)
1 minute
D)
5 minutes
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35.
What is the minimal amount of time that a nurse should scrub hands that are not visibly soiled
for effective hand
hygiene?
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Ans: A
Effective handwashing requires at least a 20-second scrub with plain soap or
disinfectant and warm water. Hands that are visibly soiled need a longer scrub.
Chapter 26, Vital Signs
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A)
A dysrhythmia
B)
Tachycardia
C)
Bradycardia
D)
Hypertension
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Upon auscultation of a client’s heart rate, the nurse notes the rate to have an irregular pattern
of 72 beats/minute. The
nurse notifies the physician because the client is exhibiting signs of which of the following?
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An irregular pattern of heartbeats is called a dysrhythmia. Tachycardia is an increased
heart rate of 100 to 180 beats/minute. Bradycardia is a pulse rate below 60
beats/minute. The normal pulse rate ranges from 60 to 100 beats per minute.
Hypertension is a blood pressure that is above normal for a sustained period.
A)
The nurse will use the arm with the highest reading.
B)
The nurse will use the arm with the lowest reading.
C)
The nurse will average the two blood pressures and document this average.
D)
The nurse will obtain a blood pressure on the client’s leg.
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2.
The nurse notes a difference in systolic blood pressure readings between the client’s arms.
How will the nurse approach
subsequent readings based upon this difference in blood pressures?
Ans: A
Feedback:
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arms. It is normal to have a 5- to 10- mm Hg difference in the systolic reading
between arms. Use the arm with the higher reading for subsequent pressures.
A)
Assess the client’s temperature by axilla.
B)
Assess the client’s skin tone and the presence or absence of sweating to determine whether the
client is febrile.
C)
Use a disposable mercury thermometer to take the client’s temperature.
D)
Take the client’s temperature rectally.
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3.
An male client 86 years of age with a diagnosis of vascular dementia and
cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has
attempted to assess his temperature using an oral thermometer, but the client is unable
to follow directions to close his mouth and secure the thermometer sublingually.
Additionally, he repeatedly withdraws his head when the nurse attempts to use a
tympanic thermometer. How should the nurse proceed with this
assessment?
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Ans: A
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The axillary site is an accurate and acceptable alternative when other sites are
impractical or contraindicated. Rectal temperatures are contraindicated in cardiac
clients; mercury thermometers are not commonly used. It is unacceptable for the
nurse to rely solely on subjective assessments to determine whether the client is
febrile.
4.
When assessing a client’s vital signs, a nursing student has explained each of her next
actions prior to assessing the client’s temperature, pulse, and blood pressure.
However, the nurse has not announced her intention to assess the client’s
respiratory rate prior to measuring it. Which of the following is a plausible rationale for the
nurse’s decision?
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A)
Respirations have both autonomic and voluntary control.
B)
The nurse likely assessed the client’s respiratory rate simultaneous to heart rate.
C)
Temperature, pulse, and blood pressure are more volatile than respiratory rate.
D)
Tachypnea is an expected finding among hospitalized individuals.
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Ans: A
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Because respiratory rate is under both autonomic and voluntary control, making the
client conscious of his or her respiratory rate prior to assessment has the potential to
affect that accuracy of the assessment. It is not possible to simultaneously assess
pulse and respirations. Temperature, pulse, and blood pressure are not necessarily
more volatile than respiratory rate. Tachypnea is not an expected finding.
Which of the following clients should the nurse monitor vital signs every four hours?
A)
A client in a critical care unit
B)
A client hospitalized for high blood pressure
C)
a resident in a long-term care facility
D)
a long-term care resident on Medicare A
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5.
Ans: B
Feedback:
Vital signs are assessed at least every four hours in hospitalized clients with elevated
temperatures, with high or low blood pressures, with changes in pulse rate or rhythm,
or with respiratory difficulty. In critical care settings, technologically advanced
devices are used to continually monitor clients’ vital signs. Regulations require
monthly vital sign measurements in long-term care residents, but if the resident is
classified as Medicare A (meaning discharged from the hospital and Medicare is
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paying for the stay to receive skilled nursing care) vital signs are taken daily.
Which is the primary source of heat in the body?
A)
Hormones
B)
Metabolism
C)
Blood circulation
D)
Muscles
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The primary source of heat in the body is metabolism, with heat produced as a
byproduct of metabolic activities that generate energy for cellular functions.
Various mechanisms increase body metabolism, including hormones and exercise.
A)
Evaporation
B)
Radiation
C)
Conduction
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7.
A nurse places a fan in the room of a client who is overheated. This is an example of heat loss
related to which of the
following mechanisms of heat transfer?
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D)
Convection
Ans: D
Feedback:
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Convection is the dissemination of heat by motion between areas of unequal density,
as occurs with a fan blowing over a warm body. Evaporation is the conversion of a
liquid to a vapor. Radiation is the diffusion or dissemination of heat by
electromagnetic waves. Conduction is the transfer of heat to another object during
direct contact.
Which of the following is an average normal temperature in Centigrade for a healthy adult?
A)
oral: 37.0°C
B)
rectal: 36.5°C
C)
axillary: 37.5°C
D)
tympanic: 34.4°C
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8.
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Ans: A
Feedback:
The normal range for an oral temperature is 37.0°C, a rectal temperature is 37.5°C,
an axillary temperature is 36.5°C, and a tympanic temperature is 37.5°C.
9.
What anatomic site regulates the pulse rate and force?
A)
Thermoregulatory center
B)
Cardiac sinoatrial node
C)
Cardiac atria and valves
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D)
Peripheral chemoreceptors
Ans: B
Feedback:
The pulse is regulated by the autonomic nervous system through the cardiac
sinoatrial node. The other anatomic sites may affect, but do not regulate, the pulse
rate and force.
Left ventricle pumps more forcefully; pulse is stronger
B)
Stimulates the vagus nerve to increase the rate
C)
Stimulates the vagus nerve to decrease the rate
D)
Right ventricle is less efficient; pulse is thready
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A)
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A client is constipated and trying to have a bowel movement. How does holding
the breath and pushing down (the 10. Valsalva maneuver) affect the pulse?
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Ans: C
Parasympathetic stimulation via the vagus nerve decreases the heart rate. The
Valsalva maneuver stimulates the vagus nerve, resulting in a slower pulse rate.
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A)
Absent and infrequent
B)
Shallow and slow
C)
Rapid and deep
D)
Noisy and difficult
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11.
The arterial blood gases for a client in shock demonstrate increased carbon dioxide and
decreased oxygen. What type of
respirations would the nurse expect to assess based on these findings?
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Ans: C
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Any condition causing an increase in carbon dioxide and a decrease in oxygen in the
blood tends to increase the rate and depth of respirations. An increase in carbon
dioxide is the most powerful respiratory stimulant.
A)
Normal body temperature
B)
Decreased body temperature
C)
Increased body temperature
D)
Fluctuating body temperature
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12.
A student is reading the medical record of an assigned client and notes the client has been
afebrile for the past 12 hours.
What does the term “afebrile” indicate?
Ans: A
Feedback:
A person with normal body temperature is referred to as afebrile.
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A)
Bradycardia
B)
Tachycardia
C)
Dysrhythmia
D)
Bigeminal
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13.
A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in
severe pain. What type of
pulse rate would be likely?
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Ans: B
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The pulse rate increases (tachycardia) and decreases in response to a variety of
physiologic mechanisms. Tachycardia is a response to an elevated body temperature
and pain.
A)
“Do you have problems breathing when you walk up stairs?”
B)
“Does your medication help you breathe better?”
C)
“How many pillows do you sleep on at night to breathe better?”
D)
“Tell me about your breathing difficulties since you stopped smoking.”
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14.
A nurse is conducting a health history for a client with a chronic respiratory problem. What
question might the nurse ask
to assess for orthopnea?
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Ans: C
Feedback:
People with difficulty breathing can often breathe more easily in an upright position, a
condition known as orthopnea. While sitting or standing, gravity lowers organs in the
abdominal cavity away from the diaphragm, giving more room for the lungs to
expand. People with orthopnea characteristically use many pillows during sleep to
accomplish this.
What population is at greatest risk for hypertension?
A)
Hispanic
B)
White
C)
Asian
D)
African American
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15.
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Ans: D
Race is a factor in hypertension, a disorder characterized by high blood pressure. It is
more prevalent and more severe in African American men and women.
16.
A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic
event is he most at risk for?
A)
Stroke
B)
Anemia
C)
Cancer
D)
Infection
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Ans: A
Feedback:
Hypertension is the most important risk factor associated with stroke.
A)
“Eat a diet high in fruits and vegetables.”
B)
“Remember to drink eight to 10 glasses of water a day.”
C)
“It is important to have increased fats in your diet.”
D)
“Put away the salt shaker and eat low-salt foods.”
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17.
A nurse educator is teaching a client about a healthy diet. What information would be included
to reduce the risk of
hypertension?
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Ans: D
High salt intake is a high risk factor for the development of hypertension.
18.
A)
A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing,
the client complains of
dizziness and faintness. The client’s blood pressure is 90/50. What is the name for this
condition?
Orthostatic hypotension
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B)
Orthostatic hypertension
C)
Ambulatory bradycardia
D)
Ambulatory tachycardia
Ans: A
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Orthostatic hypotension (postural hypotension) is a low blood pressure associated
with weakness or fainting whenone rises to an erect position (from supine to sitting,
supine to standing, or sitting to standing). It is the result of peripheral vasodilation
without a compensatory rise in cardiac output.
What site for taking body temperature with a glass thermometer is contraindicated in clients
who are unconscious?
A)
Rectal
B)
Tympanic
C)
Oral
D)
Axillary
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19.
Ans: C
Feedback:
Assessing an oral temperature with a glass thermometer is contraindicated in
unconscious, irrational, or seizure-prone adults, as well as in infants and young
children. This is due to the danger of breaking the thermometer in the mouth.
20.
A nurse is taking a client’s temperature and wants the most accurate measurement, based on
core body temperature.
What site should be used?
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A)
Rectal
B)
Oral
C)
Axillary
D)
Forehead
Ans: A
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Heat is generated by metabolic processes in the core tissues of the body, transferred
to the skin surface by the circulating blood, and then dissipated to the environment.
Core body temperatures may be measured at rectal or tympanic sites.
A)
It is an embarrassing and painful assessment.
B)
Thermometer insertion stimulates the vagus nerve.
C)
It is less expensive to take oral temperatures.
D)
It is to avoid perforating the wall of the rectum.
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21.
A hospital unit has a policy that rectal temperatures may not be taken on clients who have had
cardiac surgery. What
rationale supports this policy?
Ans: B
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Because inserting the thermometer into the rectum can slow the heart rate by
stimulating the vagus nerve, assessing a rectal temperature may not be allowed for
clients after cardiac surgery.
A)
The blood pressure does not change.
B)
The blood pressure is erratic.
C)
The blood pressure decreases.
D)
The blood pressure increases.
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22.
As adults age, the walls of their arterioles become less elastic, increasing resistance and
decreasing compliance. How
does this affect the blood pressure?
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Ans: D
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The elasticity and resistance of the walls of the arterioles help to maintain normal blood
pressure. With aging, the walls of arterioles become less elastic, which interferes with
their ability to stretch and dilate, contributing to a risingpressure within the vascular
system. This is reflected in an increased blood pressure.
23.
Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16
beats/minute. What does
this indicate?
A)
The radial pulse is more rapid than the apical pulse.
B)
This is a normal finding and should be ignored.
C)
The client’s arteries are very compliant.
D)
Not all of the heartbeats are reaching the periphery.
Ans: D
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Feedback:
A difference between the apical and radial pulse rates is the pulse deficit, and signals
that all of the heartbeats are not reaching the peripheral arteries or are too weak to be
palpated.
A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff
used is too narrow?
A)
Reading is erroneously high
B)
Reading is erroneously low
C)
Pressure on the cuff with be painful
D)
It will be difficult to pump up the bladder
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24.
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Ans: A
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The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff
is too narrow, the reading could be erroneously high because the pressure is not being
transmitted evenly to the artery.
25.
Various sounds are heard when assessing a blood pressure. What does the first sound heard
through the stethoscope
represent?
A)
Systolic pressure
B)
Diastolic pressure
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C)
Auscultatory gap
D)
Pulse pressure
Ans: A
Feedback:
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The first sound heard through the stethoscope, which is the onset of phase I of
Korotkoff sounds, represents the systolic pressure.
An adult client is assessed as having an apical pulse of 140. How would the nurse document
this finding?
A)
Bradycardia
B)
Tachycardia
C)
Dysrhythmia
D)
Normal pulse
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26.
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Feedback:
Tachycardia is a rapid pulse (heart) rate. An adult has tachycardia when the pulse
rate is 100 to 180 beats/min. Thenurse would document a rate of 140 as tachycardia.
Bradycardia is a slower than normal pulse rate. Dysrhythmia is an irregular pulse
rate.
27.
A client in a physician’s office has a single blood pressure (BP) reading of 150/92. Should the
client be taught about
hypertension?
A)
It depends on the time of day the BP was taken.
B)
It depends on whether the client is male or female.
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C)
No, a single BP reading should not be used.
D)
Yes, this reading is high enough to be significant.
Ans: C
Feedback:
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The American Heart Association recommends that blood pressure readings be
averaged on two or more subsequent occasions before diagnosing hypertension.
A)
An older adult
B)
A pregnant adolescent
C)
A junior high football player
D)
An infant 2 months of age
Ans: D
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28.
All of the following clients have a body temperature of 38°C (100.4°F). About which client
would a nurse be most
concerned?
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A mild elevation in body temperature, as is given here, might indicate a serious
infection in infants younger than 3 months of age, who do not have well-developed
temperature control mechanisms.
A)
“Just flush the glass and mercury down the toilet.”
B)
“Do not vacuum the area where it breaks.”
C)
“Open the windows and close off the room for an hour.”
D)
“Throw away any clothing exposed to the mercury.”
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29.
A home health care nurse notices that his assigned client uses a mercury thermometer. He asks
the nurse what to do if it
breaks. Which of the following is not correct?
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Mercury should never be flushed down the toilet. Mercury is not only hazardous to
people but it also pollutes the environment, especially if it gets into water. The other
responses are correct.
30.
A nurse is caring for a middle-aged client who looks worried and flares his nostrils
when breathing. The client complains of difficulty in breathing, even when he walks
to the bathroom. Which of the following breathing disorders is
most appropriate to describe the client’s condition?
A)
Hyperventilation
B)
Hypoventilation
C)
Dyspnea
D)
Apnea
Ans: C
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Feedback:
Clients with dyspnea usually appear anxious and worried. The nostrils flare as they
fight to fill the lungs with air. Dyspnea is almost always accompanied by a rapid
respiratory rate because clients work to improve the efficiency of their breathing.
The client’s condition cannot be termed hyperventilation, hypoventilation, or apnea.
Hyperventilation and hypoventilation affect the volume of air entering and leaving
the lungs. Apnea is total absence of breathing, which is life-threatening if it lasts
more than four to six minutes.
A)
Femoral
B)
Temporal
C)
Pedal
D)
Radial
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31.
A nurse needs to measure the pulse of a client admitted to the health care facility. Which site
would the nurse most
likely use?
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Ans: D
Feedback:
The radial artery is the site most commonly assessed in a clinical setting. The radial
pulse is palpated on the thumb side of the inner aspect of the wrist. Deep palpation is
required to detect the femoral pulse beneath the subcutaneous tissue, in the anterior
medial aspect of the thigh, just below the inguinal ligament, about halfway between
the anterior superior iliac spine and the symphysis pubis. The pulsation of the
temporal artery is palpated in front of the upper part of the ear;
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however, it is not the site most commonly assessed in the clinical setting. The pedal
pulse or dorsalis pedis pulse can be felt on the dorsal aspect of the foot; however, the
dorsalis pedis pulse may be congenitally absent in some clients.
A)
Pulse rate
B)
Pulse quality (amplitude)
C)
Pulse rhythm
D)
Pulse deficit
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32.
A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and
regular, 3+, and equal in radial,
popliteal, and dorsalis pedis. What does the number 3+ represent?
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Ans: B
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Pulse quality/amplitude describes the quality of the pulse in terms of its fullness,
ranging from absent (0) to bounding (4+). Pulse rates are measured in beats per
minute. Pulse rhythm is the pattern of the pulsations and the pauses between them.
The pulse deficit is the difference between the apical and radial pulse rates.
33.
A nurse has an order to take the core temperature of a client. At which of the following sites
would a core body
temperature be measured?
A)
Rectal
B)
Oral
C)
Skin surface
D)
Axillary
Ans: A
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Feedback:
Core temperatures are measured by nurses rectally. Surface body temperatures are
measured at oral (sublingual), axillary, and skin surface sites.
The nurse at the beginning of the shift plans to see which client first, based on the following
vital signs?
A)
The client age 2 years whose respiratory rate is 16 breaths/minute
B)
The newborn whose axillary temperature is 98.2 ºF (36.8 ºC)
C)
The client age 7 years whose pulse is 120 beats/minute
D)
The client age 10 years whose blood pressure is 102/62 mmHg
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34.
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Ans: A
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Normal respiratory rate for a child 1 to 3 years of age is 20 to 40 breaths/minute.
Therefore, the nurse should assess the 2-year-old with a respiratory rate of 16 first,
as the other clients’ vital signs are within normal limits.
35.
A nurse walks into a client’s room and finds him having difficulty breathing and complaining
of chest pain. He has
bradycardia and hypotension. What should the nurse do next?
A)
Take vital signs again in 15 to 30 minutes.
B)
Document the data and report it later.
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C)
Ask the client if he is anxious or afraid.
D)
Report findings to the physician immediately.
Ans: D
Feedback:
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The nurse should immediately report bradycardia associated with difficult breathing,
changes in level of consciousness, hypotension, ECG changes, and angina (chest pain).
Emergency treatment is by administering atropine intravenously to block vagal
stimulation and restore normal heart rate.
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Chapter 27, Health Assessment
A)
Ongoing partial assessment
B)
Comprehensive assessment
C)
Focused assessment
D)
Emergency assessment
Ans: A
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1.
Upon entering the client’s room at the beginning of a shift and throughout the shift,
the nurse assesses the client. The nurse considers the client’s plan of care and
response to nursing interventions during the assessments. What type of
assessment is the nurse performing?
Feedback:
An ongoing partial assessment is conducted at regular intervals during care of the
client and concentrates on identified health problems and the effectiveness of
interventions. A comprehensive assessment includes a health history and complete
physical examination and is usually conducted when a client first enters a health care
setting. A focused assessment is conducted to assess a specific problem. An
emergency assessment is a type of rapid focused assessment conducted to determine a
potentially fatal situation.
An older adult asks the nurse about the appearance of flat brown age spots on the
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A)
Senile lentigines
B)
Lanugo
C)
Senile keratosis
D)
Cherry angiomas
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2.
hands. After examining the client’s hands, the nurse recognizes these skin
characteristics as a common skin variation in the older adult and documents the
variations as which of the following?
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Senile lentigines are flat, brown age spots, senile keratosis are raised, dark areas, and
cherry angiomas are small, round red spots. All are common skin variations in the
older adult. Lanugo is a fine downy hair that appears on the newborn for the first two
weeks of life.
A)
Decreased heart rate
B)
Visible pulsation through a thin chest wall
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3.
The nurse is performing an assessment on an infant. Which finding is considered an abnormal
cardiovascular assessment
that should be documented and reported to the physician?
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C)
Sinus dysrhythmia that increases with inspiration and decreases with expiration
D)
Presence of an S heart sound
Ans: A
Feedback:
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Infants and children should have a more rapid heart rate, instead of a decreased heart
rate, until about age 8 years. Common cardiovascular findings include visible
pulsation if the chest wall is thin, sinus dysrhythmia (the rate increases with
inspiration and decreases with expiration), and the presence of an S heart sound.
A)
The client states that a mole on his forehead has become larger in recent months.
B)
Decreased skin turgor is evident when the skin is folded and then released.
C)
Small, round, red spots are present on the client’s forearms bilaterally.
D)
There are some raised, brown areas on the backs of the client’s hands.
Ans: A
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4.
The nurse is conducting an assessment on the integumentary system of a client age 74 years.
Which of the following
findings should the nurse document as an anomaly that may warrant follow-up?
Feedback:
Changes in the size or appearance of a mole always require further assessment and
follow-up due to their association with skin cancer. Decreased skin turgor is an
expected finding in older adults, as are diffuse red spots (cherry angioma) and raised,
dark areas (senile lentigines).
5.
As a component of a head to toe assessment, the nurse is preparing to assess convergence of
the client’s eyes. How
should the nurse conduct this assessment?
A)
Ask the client to follow her finger as she slowly moves it towards the client’s nose.
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B)
Ask the client to look ahead while slowly bringing a pen light in from the side and to the
client’s pupil.
C)
Ask the client to hold his head stationary while following a pencil from left to right.
D)
Ask the client to read a Snellen chart from a distance of 20 feet.
Ans: A
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Eye convergence is assessed by holding your finger 6″ to 8″ from the patient’s nose
and asking the patient to follow it as it moves closer. A pen light is used to assess
pupillary reaction. Visual acuity is assessed with the use of a Snellen chart. Following
a pencil from side to side is a test for extraocular movements.
A nurse is conducting a health assessment. How will the information collected from the client
be used?
A)
As a basis for the nursing process
B)
To illustrate nursing competence
C)
To facilitate nurse–client caring
D)
As one component of medical care
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6.
Ans: A
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Health assessment is an integral component of nursing care and is the basis of the
nursing process. Health assessments by nurses are used to plan, implement, and
evaluate education and care. Nursing assessment is different from other types of
health care provider assessments, as it is a holistic collection of information about a
client’s level of health.
B)
Ongoing partial
C)
Focused
D)
Emergency
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Comprehensive
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A)
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7.
A home health nurse is visiting a client who recently was hospitalized for repair of a fractured
hip. The client tells the
nurse, “I have had a lot of pain in my abdomen.” What type of assessment would the nurse
conduct?
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Ans: C
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A focused assessment is conducted to assess a specific problem. In this case, the
nurse would ask the client abouturinary frequency, bowel movements, and diet, and
then take vital signs and assess the abdomen. Comprehensive assessments include a
detailed health history and physical assessment. Ongoing partial assessments are
conducted at regular intervals, and emergency assessments are carried out in
emergency situations (such as prior to CPR).
8.
An adolescent comes to a community health clinic with complaints of vaginal itching and
discharge. She believes it is
from having sex with her boyfriend. Which response should the nurse use during the health
history to elicit information?
A)
“Tell me about the sexual activity with your boyfriend.”
B)
“Why did you ever have sex with someone you don’t know?”
C)
“You are old enough to know to use condoms.”
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D)
“I don’t understand how you could be so careless.”
Ans: A
Feedback:
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The health history is used to collect subjective data about the client’s health status.
Nurses use therapeutic communication skills, including open-ended statements and
questions that are not threatening or negative, to establish an effective nurse–client
relationship that facilitates communication.
A)
“This is nothing to worry about. I won’t hurt you.”
B)
“Some of the examination may be painful, but I will be gentle.”
C)
“Let me tell you what I will be doing. It should not be painful.”
D)
“I have to do this, so just relax and it won’t last long.”
Ans: C
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9.
A nurse is preparing a client for a physical assessment. The client appears anxious about the
assessment. Which
statement by the nurse would be most appropriate?
Feedback:
The client may be anxious for many reasons. Tell the client that the assessments
should not be painful. Explaining the assessment in general terms can help decrease
the client’s embarrassment, fear of possible abnormal physical findings, or fear of
“failing” a test.
10.
What would a nurse ensure before beginning a health assessment?
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A)
That the time needed for the assessment fits into the nurse’s work schedule
B)
That the room is private, quiet, warm, and has adequate light
C)
That family members are present to answer specific questions
D)
That there is a written physician’s order for the assessment
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Ans: B
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The nurse and client should agree on a time for the assessment. The room (or area)
should be private, quiet, and warm enough to prevent chilling, and it should have
adequate lighting, either by sunlight or overhead fixtures. Family members may
remain, especially if they are needed to explain activities to the client. A nursing
assessment does not require a physician’s order.
A)
Snellen chart
B)
Stethoscope
C)
Ophthalmoscope
D)
Otoscope
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11.
A nurse working in a clinic is planning to conduct vision screenings for a group of lowincome women. What equipment
would be needed to test vision?
Ans: A
Feedback:
A Snellen chart is used as a screening test for distant vision. It consists of characters
in 11 lines of different-sized type, with the largest characters at the top of the chart
and the smallest characters at the bottom. Vision is recorded as a score; for example,
20/20 is normal vision. A stethoscope is used to auscultate body sounds. An
ophthalmoscope is used to assess the inner eye. An otoscope is used to inspect the
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nasal passages.
A)
Describe the equipment and how it works.
B)
Show pictures of functions of the equipment.
C)
Draw pictures of the anatomy to be assessed.
D)
Warm the equipment with hands or warm water.
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12.
When using assessment equipment that will touch the client, what should the nurse do before
conducting the
assessment?
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Ans: D
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Equipment that will touch the client during a physical examination should be warmed
by the examiner’s hands or warm water before use.
A)
Tuning fork
B)
Percussion hammer
C)
Speculum
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13.
A school nurse is preparing to test the auditory function of grade school students. What
equipment will be needed for
this examination?
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D)
Ophthalmoscope
Ans: A
Feedback:
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A tuning fork is a two-pronged metal instrument used to test auditory function and
vibratory perception. The fork is activated to vibrate by holding the base and gently
tapping the prongs against the palm of the examiner’s hand. Once vibrating, the fork
is held at the base to avoid diminishing the vibration.
A nurse is preparing to examine the breasts of a client. In what position should the nurse place
the client?
A)
Prone
B)
Standing
C)
Dorsal recumbent
D)
Lithotomy
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Ans: C
Feedback:
The dorsal recumbent position is used to assess the head, neck, anterior thorax, lungs,
heart, breasts, extremities, and peripheral pulses. The prone position is used to assess
the hip joint and posterior thorax. The standing position is used to assess posture,
balance, and gait. The lithotomy position is used to assess female genitalia and
rectum.
15.
A nurse is using inspection as an assessment technique. What does the nurse use during
inspection?
A)
Equipment such as a stethoscope
B)
Both hands to produce sounds
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C)
Light palpation to detect surfaces
D)
Senses of vision, hearing, smell
Ans: D
Feedback:
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Inspection is the process of performing deliberate, purposeful observations. The
nurse observes visuallybut also uses hearing and smell to gather data throughout the
assessment. A stethoscope is used for auscultation, and the hands are used to percuss
and palpate.
Which of the following can a nurse assess by palpation?
A)
Heart sounds, lung sounds, blood pressure
B)
Temperature, turgor, moisture
C)
Vision, hearing, cranial nerves
D)
Tissue density, gait, reflexes
Ans: B
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16.
Feedback:
Palpation is an assessment technique that uses the sense of touch. The hands and
fingers can assess temperature, turgor, texture, moisture, vibrations, and shape.
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A)
Resonance
B)
Turgor
C)
Quality
D)
Texture
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17.
When auscultating a client’s abdomen, a nurse notes gurgling sounds. What characteristic of
sound would the nurse
document?
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Ans: C
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Auscultation is the act of listening with a stethoscope to sounds produced within
the body. Four characteristics are assessed and documented: pitch (high to low),
loudness (soft to loud), quality (gurgling or swishing), and duration (short,
medium, long). Resonance is measured with percussion. Turgor and texture are
assessed with palpation.
A)
Taking vital signs
B)
Palpating the integument
C)
Identifying risk factors for altered health
D)
Assessing the head and neck
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18.
A nurse is performing a general survey of a client admitted to the hospital. Which of the
following actions is an element
of this procedure?
Ans: A
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The general survey is the first component of the physical assessment. It includes
observing the client’s overall appearance and behavior, taking vital signs, and
measuring height and weight. Information from the general survey provides clues to
the client’s overall health. Palpating the integument and assessing the head and neck
are part of the physical assessment. Identifying risk factors for altered health occurs
in the health history.
A)
Jaundice
B)
Cyanosis
C)
Erythema
D)
Pallor
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19.
When inspecting the skin of a client, the nurse notes a bluish tinge to the skin. What condition
would the nurse
document?
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Ans: B
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Cyanosis is a bluish or grayish discoloration of the skin in response to inadequate
oxygenation. Jaundice is a yellow color of the skin resulting from liver and
gallbladder disease, some types of anemia, and excessive hemolysis. Erythema is
redness of the skin associated with sunburn, inflammation, fever, trauma, and
allergic reactions. Pallor is paleness of the skin, which often results from a decrease
in the amount of circulating blood
or hemoglobin, causing inadequate oxygenation of the body tissues.
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A)
Macule
B)
Wheal
C)
Vesicle
D)
Nodule
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20.
The nurse palpating the skin of a client documents a firm 1.5 cm mass on the lower right leg.
What type of skin lesion
does this describe?
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Ans: D
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A nodule is a mass 0.5 cm to 2 cm that is firmer than a papule. A macule is a lesion
that is 1 cm or smaller. A wheal is an irregular, superficial area of localized skin
edema. A vesicle is a 1 cm or less lesion filled with serous fluid.
A)
Visual acuity
B)
Extraocular movements
C)
Peripheral vision
D)
Existence of cataracts
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21.
A nurse assesses a client’s eyes by testing the cardinal fields of vision for coordination and
alignment. What eye
characteristic is being assessed by this process?
Ans: B
Feedback:
The nurse tests for extraocular movements by assessing the cardinal fields of vision
for coordination and alignment. Normally both eyes move together, are coordinated,
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and are parallel. Visual acuity is assessed with the Snellen chart. Tests for peripheral
vision (or visual fields) are used to assess retinal function and optic nerve function.
Full peripheral vision is normal. Cataracts are noted by inspection (cloudiness of the
lens).
A)
Bronchial
B)
Bronchovesicular
C)
Vesicular
D)
Adventitious
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22.
While conducting a physical examination of the thorax, a nurse notes and documents breath
sounds as moderate
“blowing” sounds with equal inspiration and expiration. What type of breath sounds are these?
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Ans: B
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Bronchial breath sounds are high pitched, with expiration longer than inspiration.
Bronchovesicular sounds are moderate “blowing” sounds with equal inspiration and
expiration. Vesicular sounds are soft and low-pitched, with longer inspiration than
expiration. Adventitious sounds are not normally heard in the lungs.
23.
A nurse is conducting a health assessment for an African American client. What should the
nurse consider in terms of
cultural sensitivity?
A)
All individuals, regardless of culture, have the same anatomy and physiology.
B)
Asking specific questions about race during the health history
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C)
Cultural risk factors for alterations in health and normal racial variations
D)
Differences in emotional, social, and spiritual basic human needs
Ans: C
Feedback:
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The person’s culture does not affect how a health assessment is conducted, but it is
an integral component of nurse– client interactions. Nurses should know risk factors
for alterations in health based on racial inheritance, as well as normal variations that
occur among races.
When conducting a physical assessment, what should the nurse assess and document about
size and shape of body parts?
A)
Actual measurements in centimeters
B)
Symmetry (comparison of bilateral body parts)
C)
Indications of general health status
D)
Vital signs of all extremities (arms and legs)
Ans: B
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24.
Feedback:
When conducting a physical assessment, the nurse assesses and compares all bilateral
body parts. The symmetry of parts of the body (such as the skull) and the extremities
(arms and legs) is an important assessment to document.
25.
While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds?
A)
Air in the lungs
B)
A narrowing of the upper airway
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C)
Narrowed small air passages
D)
Moisture in air passages
Ans: D
Feedback:
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Crackles are fine-to-coarse crackling sounds made as air moves through wet
secretions. They are described as “fine” when air passes through moisture in small air
passages, and as “coarse” when air passes through moisture in the bronchioles,
bronchi, and trachea. A wheeze is produced by narrowed air passages. The lungs
normally contain air.
When assessing the abdomen, which assessment technique is used last?
A)
Inspection
B)
Auscultation
C)
Percussion
D)
Palpation
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26.
Feedback:
The sequence of techniques used to assess the abdomen is inspection, auscultation,
percussion, and palpation. Percussion and palpation stimulate bowel sounds and thus
are done after auscultation of the abdomen.
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What is one purpose of documentation of the health assessment?
A)
To identify the nurse’s role in health care
B)
To identify actual and potential health problems
C)
To expand nursing knowledge and skills
D)
To provide a basis for evidence-based nursing
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27.
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Ans: B
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The nurse organizes and documents assessment data to identify actual and potential
health problems, to make nursing diagnoses, to plan appropriate care, and to evaluate
the client’s response to treatment.
A)
Sclera
B)
Nailbeds
C)
Lips
D)
Palm
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28.
An African American client with jaundice has been admitted to the health care facility. Which
of the following body
areas is the best place to assess jaundice?
Ans: A
Feedback:
In African American clients, the sclera is the best place to assess the yellowish
discoloration of jaundice. Jaundice assessment cannot be done on the nailbeds, lips,
or palm due to hyperpigmentation.
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A)
The shoulder and upper back curves forward
B)
The lumbar region tends to curve inward
C)
The sacral region tends to turn outward
D)
A portion of the spine is curved to the side laterally
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29.
A nurse is assessing the spine of a client with kyphosis. Which of the following would the
nurse expect to observe about
the client’s posture?
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Ans: A
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In kyphosis, the shoulder and upper back tend to curve forward. In lordosis, the
lumbar region curves inward and the sacral region curves outward. Scoliosis is a
curvature of a portion of the spine to the side, laterally.
A)
Focused assessment
B)
Spiritual assessment
C)
Social assessment
D)
Comprehensive assessment
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30.
During a nurse’s visit to the client’s home, the client states, “I have pain in my right knee.”
The nurse assesses the
client’s right knee. What kind of assessment is this?
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Ans: A
Feedback:
Often, nurses must select the most important interviewing questions or assessment
techniques to use, and perform a focused health assessment based on the client’s
problem.
Which framework is used during the focused assessment?
A)
Functional health assessment
B)
Head-to-toe framework
C)
Conceptual framework
D)
Body systems framework
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31.
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Ans: D
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Body systems approach is used during the focused assessment of an acutely or
critically ill client to determine function of a particular body system.
32.
The nurse is preparing to assess a client’s cranial nerves. Which of the following techniques
should you use to assess
cranial nerve III?
A)
Shine a bright light in the client’s eye and observe for bilateral pupillary response.
B)
Ask the client to close the eyes, occlude a nostril, then identify the smell of different
substances.
C)
Determine visual acuity using a Snellen chart
D)
Occlude the patient’s right ear, whisper a word into the left ear, and ask the patient to repeat it.
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Ans: A
Feedback:
This technique is used to assess CN VIII (Acoustic).
How would a nurse assess a client for pupillary accommodation?
A)
Using an ophthalmoscope, check the red reflex.
B)
Ask the client to focus on a finger and move the client’s eyes through the six cardinal
positions of gaze.
C)
Ask the client to focus on an object as it is brought closer to the nose.
D)
Ask the client to read the smallest possible line of letters on the Snellen chart.
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33.
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Ans: C
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The normal pupillary response is constriction, and convergence when focusing on
a near object. Presence of the red reflex indicates that the cornea, anterior chamber,
and lens are free of opacity and clouding. Answer B evaluates the function of each
of the eye muscles and cranial nerves. The Snellen chart tests visual acuity.
34.
During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle
the forehead, and puff out
the cheeks. What nerve is being tested by this action?
A)
Cranial nerve I
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B)
Cranial nerves II and III
C)
Cranial nerve VII
D)
Cranial nerve VIII
Ans: C
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Cranial nerve VII is the facial nerve tested by smiling, frowning, wrinkling the
forehead, and puffing out the cheeks. CNI is the olfactory nerve, CNII and III are the
optic and oculomotor nerves, and CNVIII is the acoustic nerve.
A)
Supine
B)
Sims
C)
Prone
D)
Lithotomy
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35.
The nurse preparing to perform an abdominal assessment on a client places the client in which
of the following
positions?
Ans: A
Feedback:
The nurse should place the client in the supine position when performing an abdominal
assessment.
Chapter 28, Safety, Security, and Emergency Preparedness
1.
The clinical nurse educator at a long-term care facility is responsible for organizing and
carrying out staff education
sessions. Which of the following topics for staff education is most likely to benefit the greatest
number of residents?
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A)
Educating nurses on how to prevent falls
B)
Reviewing safe medication administration
C)
Educating nurses on how to prevent wandering by confused residents
D)
Reviewing resuscitation for cardiac and respiratory arrest
Ans: A
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Falls remain the leading cause of death among older adult Americans. Education that
aims to reduce the incidence of falls is likely to be of more benefit than measures
that address medication administration, prevention of wandering, or resuscitation
procedures, even though such topics may be of importance.
A)
Routine screening of newly admitted clients
B)
Focused physical assessment for IPV for all new clients
C)
Involvement of a social worker in the admission assessment of all new female clients
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2.
Which of the following measures should nurses implement in a hospital setting in order to
identify intimate partner
violence (IPV)?
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D)
Review of the definition and legal repercussions of IPV with all new female clients
Ans: A
Feedback:
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Practices related to the identification of IPV vary, but it is generally agreed that a
simple screening tool can be an effective strategy. A focused physical assessment and
the involvement of social work are not warranted for all clients. A review of the
definition and repercussions of IPV is likely not as effective as a simple and direct
screening tool.
A)
Orient the client to the room and environment thoroughly upon admission.
B)
Provide the client with a bedpan to reduce the need to transfer to a commode or washroom.
C)
Administer pain medications sparingly in order to minimize cognitive or musculoskeletal side
effects.
D)
Place the client in a shared room with a client who is stable and oriented.
Ans: A
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3.
A nurse is admitting a client to a geriatric medicine unit following the client’s recent
diagnosis of acute renal failure. Which of the following nursing actions is most likely
to reduce the client’s chance of experiencing a fall while on the
unit?
Feedback:
A person who is familiar with his or her surroundings is less likely to experience an
accidental injury. As part of the hospital admission routine, it is important to orient
the client to the safety features and equipment in the room. A bedpan should not be
used for the sole reason of reducing the risk of falls, and pain medication should be
provided in doses sufficient to treat the client’s pain. A client should never be charged
with supervising the safety of another client.
4.
Which of the following clients is most likely to face an increased risk of falls due to his or her
medication regimen?
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A)
A female client age 77 years who has received a benzodiazepine to minimize her anxiety
B)
A male client age 79 years whose recent high blood pressure has required a PRN dose of an
angiotensin-converting
enzyme (ACE) inhibitor
C)
A woman age 81 years who has required a blood transfusion to treat a gastrointestinal bleed
D)
A man 90 years of age whose venous ulcer has required the administration of intravenous
antibiotics
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While all drugs carry some risk of adverse effects, the use of benzodiazepines and
antiepileptics are more predicative of falls than are other drug families.
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A girl age 4 years has been admitted to the emergency department after accidently ingesting a
cleaning product. Which
of the following treatments is most likely appropriate in the immediate treatment of the girl’s
poisoning?
Administration of activated charcoal
B)
Inducing vomiting
C)
Gastric lavage
D)
Intravenous rehydration
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A)
Ans: A
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Activated charcoal is the most common treatment for many poisonings and is more
effective and safe than induced vomiting or gastric lavage. Rehydration is likely
necessary, but this does not actively treat the girl’s poisoning.
A)
Tie the client’s hand restraint to the bed frame rather than the side rail.
B)
Obtain a physician’s order for the restraints within 24 hours.
C)
Ensure the client is under continuous surveillance while restrained.
D)
Choose a restraint device that best minimizes the client’s mobility.
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6.
In light of the failure of alternatives, a nurse has been forced to physically restrain an agitated
client. Which of the
following actions should the nurse perform when applying and maintaining the restraints?
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Ans: A
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Restraints should be tied to the frame of the bed rather than to the side rails. A
physician’s order is needed for restraints, except in emergencies when an order must
be obtained within one hour of application. Frequent assessment of the client is
needed, but continuous surveillance is not necessarily required. The least restrictive
type of device that allows the greatest mobility, while still ensuring safety, is chosen.
7.
A client is very anxious and states, “I am so stressed.” Why do these factors affect the client’s
safety?
A)
Stress increases retention of information
B)
Stress affects interpersonal relationships
C)
Stress increases concern about hazards
D)
Stress tends to narrow the attention span
Ans: D
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Feedback:
Stressful situations tend to narrow a person’s attention span and make him or her
more prone to accidents. Stress does not increase retention of information or concern
about hazards. Although stress may affect interpersonalrelationships, that is not the
same as safety.
A)
“Always test the temperature of bath water before stepping in.”
B)
“Take your insulin twice a day as we have discussed.”
C)
“Remember to follow your diet so you lose weight this month.”
D)
“Rub lotion on the skin of your legs and feet twice a day.”
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8.
A client with diabetes has impaired sensation in her lower extremities. What education would
be necessary to reduce her
risk of injury?
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Alterations in sensory perception can have a serious effect on safety. A client whose
tactile sense is impaired may not perceive temperature extremes that are a threat to
safety. Although all the other statements may be necessary, they do not promote
safety.
9.
Which of the following people has the greatest risk for accidental injury?
A)
An infant just learning to crawl
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B)
An older adult who walks two miles a day
C)
An athlete who exercises on a regular basis
D)
A worker who operates industrial machines
Ans: D
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Certain occupations, lifestyles, and environments place people in more hazardous
situations. A worker who operates industrial machines is at greater risk for accidental
injury as well as for hearing loss.
What age group is most vulnerable to toxic fumes or asphyxiation?
A)
Young children
B)
Adolescents
C)
Toung adults
D)
Middle adults
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Most exposure to toxic fumes, such as carbon monoxide, occurs in the home. Young
children and older adults are more vulnerable to toxic fumes. Suffocation, or
asphyxiation, can occur at any age, but the incidence is greater in children.
11.
What safety device for children is mandated by law in all 50 states?
A)
Bumper pads in baby cribs
B)
Infant car seats and carriers
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C)
Automatic hot water heater controls
D)
Parental controls for Internet access
Ans: B
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All 50 states mandate the use of infant car seats and carriers when transporting a child in a
motor vehicle.
A)
Nothing; the nurse has no control over the toddler’s home.
B)
Refer the caregivers of the toddler to a home health nurse.
C)
Verbally confront the caregivers about the suspicions.
D)
Report suspicions about the abuse to proper authorities.
Ans: D
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12.
An emergency room nurse is assessing a toddler with multiple bruises and burns. The nurse
suspects the toddler has
been abused. What is legally required of the nurse?
Feedback:
Nurses are both legally and ethically obligated to report abuse, either suspected or
confirmed. In many states, the failure to report actual or suspected abuse is a crime.
The role of the nurse does not include confrontation.
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A)
All school-age children need to be secured in safety seats.
B)
Booster seats should be used for children until they are 4 feet 9 inches tall or at least 8 years of
age.
C)
Children under 8 years old should ride in the back seat.
D)
All school-age children need to be secured in lap seat belts.
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13.
A grade school nurse is addressing parents at a PTA meeting regarding car safety. Which of
the following is a
recommended safety guideline for this age group?
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All school-age children need to be secured in safety seats, belt-positioning booster
seats, or shoulder lap belts for their size. The National Highway Traffic Safety
Administration recommends booster seats for children until they are 4 feet 9 inches
tall or at least 8 years of age, and all children 12 and under should ride in the back
seat to eliminate the risk of injury from airbag deployment (National Highway Traffic
Safety Administration [NHTSA], 2008).
A)
A scar over the navel
B)
A local and/or systemic infection
C)
A greater acceptance by peers
D)
A strained relationship with parents
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14.
An adolescent has recently had a ring inserted into her navel. Which of the following is the
greatest risk facing the
adolescent as a result of this activity?
Ans: B
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Body piercing is a quick procedure that does not require anesthesia, but the risk for
infection is great. This risk includes local infection, hepatitis B virus, and HIV.
A)
Keep bed in the high position.
B)
Keep side rails up at all times.
C)
Apply restraints to all confused clients.
D)
Lock wheels on beds and wheelchairs.
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15.
Nurses provide many interventions to prevent falls in health care settings. Which of the
following would be an
appropriate intervention to prevent falls?
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Locking wheels on beds and wheelchairs prevents them from rolling and precipitating
a fall. Beds should be kept in low positions with the side rails down in most
situations; restraints should be applied only as a last resort.
16.
A nurse makes a medication error and fills out an incident report. What will the nurse do with
the incident report once it
is filled out?
A)
Place it in the client’s medical record.
B)
Take it home and keep it locked up.
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C)
Maintain it according to agency policy.
D)
Include it with documentation of the error.
Ans: C
Feedback:
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An accident in a health care agency requires filling out an incident report, a
confidential document that objectively describes the circumstances of the accident.
The incident report is not a part of the medical record and should not be mentioned in
the documentation. The report is maintained by the agency.
In what situation would the use of side rails not be considered a restraint?
A)
The nurse keeps them raised at all times.
B)
The institution’s policies mandate using side rails.
C)
A visitor requests their use.
D)
A client requests they be up at night.
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17.
Feedback:
It is now recognized that side rails can pose serious risks for some clients. However,
side rails are not considered restraints if the client requests they be put up at night to
increase feelings of security while asleep. Agency policies help nurses determine
when to apply restraints and what type to use.
18.
Bioterrorism has become a commonly used term. What is the definition of bioterrorism?
A)
A verbal threat by those wishing to harm specific individuals
B)
A written threat calculated to produce terror in a family
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C)
The deliberate spread of pathogens into a community
D)
A worldwide plan to produce illness and injury
Ans: C
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Bioterrorism involves the deliberate spread of pathogenic organisms into a community.
A)
Antimicrobials
B)
Narcotics
C)
Antihistamines
D)
Antacids
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19.
A client arrives at the emergency department with nausea, hematemesis, fever,
abdominal pain, and severe diarrhea. There is a suspicion the client has been exposed
to the anthrax bacillus. What category of medications will be
administered?
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Anthrax is a potentially fatal bacterial infection. The recommended treatment for
exposure to, as well as symptoms of, an anthrax infection is with rapid
administration of antimicrobial therapy. Narcotics are administered to manage pain.
Antihistamines are prescribed to manage allergy conditions. Antacids are prescribed
to manage gastrointestinal disorders.
A)
“I will turn off the outside lights and lock the doors every night.”
B)
“Do you think it would be best for me to buy a gun?”
C)
“I am going to remove all those throw rugs on the floor.”
D)
“Well, I always let the boys play in the bathtub; they love it.”
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20.
What statement by a client would indicate that a nurse had successfully implemented a
educating/learning strategy to
prevent injury in the home?
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Nurses must evaluate the effectiveness of their interventions to promote safety and
prevent injury. If the expected client outcomes have been met and evaluative criteria
satisfied, the client should be able to correctly identify real and potential unsafe
environmental situations, and implement safety measures in the environment.
21.
A nurse is caring for a stable toddler diagnosed with accidental poisoning, due to the ingestion
of cleaning solution.
What must be included in educating parents about how to protect a toddler from accidental
poisoning?
A)
Closely monitor the toddler’s activity.
B)
Label poisonous solutions.
C)
Keep cleaning solutions locked up.
D)
Do not leave the toddler alone.
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Ans: C
Feedback:
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The parents should keep cleaning solutions locked up to protect the toddler from
accidental poisoning. Accidental poisonings usually occur among toddlers and
commonly involve substances located in bathrooms or kitchens. Labeling poisonous
substances may not help as toddlers are unable to read. Not leaving the child alone
and closely monitoring the child are important, but not feasible all the time.
When educating parents of preschoolers, what is most important to include in your
presentation?
A)
Use wrist guards with rollerblades
B)
Teach preschoolers to tread water
C)
Keep chemicals in a locked cabinet
D)
Strict discipline with potty training
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Ans: C
Feedback:
Increasing mobility, lack of life experience and judgment, and immature
musculoskeletal and neurologic systems lead to potentially hazardous encounters for
toddlers and preschoolers.
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Back injuries
B)
Bloodborne pathogens
C)
Adverse reproduction
D)
Neurologic disorders
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23.
The facility risk management team is preparing an in-service to nursing staff
members. The presentation will highlight risk factor increase related directly to the
type of clientele on a nursing unit. The presenter will correctly explain that
which of the following risks is increased for female nurses who work on an oncology care
unit?
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Common risks in health care facilities are exposure to bloodborne pathogens from
stick injuries via used needles, back injuries caused by heavy lifting, and potential
adverse reproductive outcomes as a result of overexposure to antineoplastic
medications. On oncology divisions, the nurse is continually exposed to
antineoplastic agents.
A)
Alternative measures attempted before applying the restraints
B)
A verbal order for renewal of the restraints every 48 hours
C)
Detailed description of the restraint application process
D)
Type of personal protective equipment (PPE) used by the nurse during restraint application
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24.
The nurse is caring for a client who has prescribed extremity restraints. The nurse is required
to document which of the
following?
Ans: A
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This is not typically documented.
A)
Briefly leave the client in order to call the primary physician to assess the client’s condition.
B)
Order x-rays or CT scans for the client, as needed.
C)
Document the incident, assessment, and interventions in the client’s medical record.
D)
Do not file an event report unless the client is seriously injured in the fall.
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25.
A nurse enters a client’s room and finds that the client has fallen on her way to the bathroom.
Which of the following is
a prudent nursing intervention for this client?
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The nurse is responsible for documenting the incident in the client’s record. Assess the
patient immediately and provide appropriate care and interventions based on client
status, and ensure prompt follow-through for any physician orders for diagnostic tests.
An event report should be filed in the case of a fall, as per facility policy.
26.
A doctor orders restraints for an older adult client who is disoriented from the pain medication
she is taking. Which of
the following is an appropriate guideline for applying these restraints?
A)
Chemical restraints should be tried before using physical restraints.
B)
The restraints can be ordered by the nursing supervisor in emergency situations.
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C)
The client’s vital signs must be assessed every hour.
D)
Adults must be reassessed within 4 hours; children age 9 to 17 years within two hours; and
children under 9 years within
one hour.
Ans: D
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Client with restraints must be monitored and reassessed as described in answer D.
Restraints must be ordered by a physician, and client vital signs must be assessed
every two hours.
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27.
A physician orders restraints for a confused client who is at risk for injury by pulling out tubes
necessary to sustain her
life. Which of the following statements describes an accurate action to take when applying
these restraints?
Apply restraints to the hands or wrists, never to the ankles.
B)
Ensure that two fingers can be inserted between the restraint and the client’s extremity.
C)
Use a quick-release knot to tie the restraint to the side rail.
D)
Remove the restraint at least every four hours, or according to agency policy.
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A)
Ans: B
Feedback:
Restraints should be sufficiently loose for two fingers to be inserted between the
restraint and the extremity. Restraints can be placed on ankles; quick-release knots
should be tied to the bed frame, not the side rail. Restraints should be removed every
two hours.
28.
Which of the following populations, based on their development stage, would benefit from
strategies to prevent falls?
Select all that apply.
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Newborns
B)
Toddlers
C)
Adolescents
D)
Adults
E)
Older Adults
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Educate parents never to leave newborns alone on a changing table, and also teach
parents of toddlers to childproof the home. Parents of preschoolers should make sure
their children wear proper safety equipment when riding bicycles or scooters.
Adolescents and adults are not at high risk for falls. Older adults, however, are at risk
for falls due to the effects of aging on the body systems.
After a client falls out of bed, the nurse completes which of the following?
A)
Safety event report (incident report)
B)
Telephone call to hospital’s attorney
C)
Progress note stating event report was completed
D)
Malpractice report
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29.
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Ans: A
Feedback:
An accident or incident that compromises safety in a health care agency requires the
completion of a safety event report. This is a confidential document, formerly
referred to as an incident report. The safety event report is not a part of the medical
record and should not be mentioned in the documentation.
A)
As soon as the disaster is announced publicly
B)
When officially informed that a disaster has occurred
C)
After the first disaster has been experienced
D)
In advance of a possible emergency or disaster
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30.
The nurse knows that a health care facility should determine its disaster-preparedness plan for
delivering care in the
event of an emergency or disaster?
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Feedback:
Each health care facility should determine in advance how to deliver care, if an
emergency or disaster occurs. This involves collaboration with internal committees
and external agencies.
31.
A nurse is assessing a client who recently had a stroke. What is one area of assessment
necessary to promote safety?
A)
Neuromuscular
B)
Respiratory
C)
Gastrointestinal
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D)
Genitourinary
Ans: A
Feedback:
Anything that affects a patient’s health state potentially can affect the safety of the
environment. For example, a nurse who is assessing a patient with a recent stroke
would assess neuromuscular impairment to prevent falls.
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32.
A nurse specializes in caring for victims of domestic violence. Which of the following
statements accurately describes
domestic violence in the United States? (Select all that apply.)
Studies indicate that each year, more than 12 million adults in the United States are victims of
intimate partner violence.
B)
Intimate partner violence is domestic violence or battering between two people in a close
relationship.
C)
Many men who batter their spouses also batter their children.
D)
There is no evidence linking childhood sexual abuse to adult physical symptoms or substance
abuse.
E)
Domestic violence is not seen in a cycle.
Ans: A, B, C
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A)
Feedback:
Studies indicate that each year, more than 12 million adults in the United States are
victims of intimate partner violence. Intimate partner violence is domestic violence or
battering between two people in a close relationship. Many men who batter their
spouses also batter their children. Recent evidence suggests a relationship between
childhood sexual abuse
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and certain physical symptoms in adulthood, such as gastrointestinal symptoms,
eating disorders, and substance abuse. The nurse may be involved directly in health
education and counseling measures, or may suggest other resources to the family as
additional support for safety, well-being and to interrupt the cycle of violence.
33.
Prior to inserting a nasogastric tube, the nurse correctly verifies the client’s identity through
which of the following
methods?
A)
Ask the client: “Is your name
B)
Check the client’s identification bracelet.
C)
Verify the client’s room number.
D)
Call the client by his or her first name.
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The Joint Commission’s National Patient Safety Goals include improving the
accuracy of client identification. The nurse should check the client’s identification
bracelet to verify the client’s identity.
34.
Which of the following nursing diagnoses would be appropriate for teaching interventions for
a single mother who
leaves her toddler unattended in the bathtub?
A)
Noncompliance
B)
Risk for Suffocation
C)
Risk for Falls
D)
Risk for Imbalanced Body Temperature
Ans: B
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Feedback:
Death from drowning occurs from suffocation. Nearly half of all drowning victims
are children under the age of 5. Most drowning deaths in young children occur
because of inadequate supervision of a bathtub or pool.
A)
Toxic spill
B)
Earthquake
C)
War
D)
Terrorist event
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35.
The nurse conducting a community emergency preparedness education class includes which of
the following as an
example of a natural disaster?
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A disaster is broadly defined as a tragic event of great magnitude that requires the
response of people outside the involved community. Disasters can be categorized as
natural (e.g., massive flooding following a hurricane or an earthquake) or man-made
(e.g., a toxic spill, war, or a terrorist event).
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Chapter 29, Complementary and Alternative Therapies
A)
Guided imagery
B)
Yoga
C)
Prayer
D)
Aromatherapy
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1.
A nurse is using a technique that involves the five senses to visualize recovering from an
upcoming surgical procedure.
What type of technique is the nurse teaching the client to use?
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Guided imagery involves using five senses to imagine an event or body process
unfolding according to plan. Yoga is the practice of physical postures that promotes
strength and flexibility. Prayer does not involve the five senses and is difficult to
measure. Aromatherapy is the use of essential oils of plants to treat symptoms.
A)
Some herbs or supplements may interact with a client’s prescribed medications.
B)
Nurses have special knowledge related to the use of herbs and supplements.
C)
Some herbs or supplements require a special diet.
D)
The herb or supplement may need to be acquired from another country.
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2.
Why is it important to obtain information from a client related to the use of herbal
supplements during a nursing
assessment?
Ans: A
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Some herbs and supplements may interact with prescribed medications, so the nurse
needs to document the herbs or supplements that the client reports taking. Extensive
specialized training is required before a nurse can be competent to advise clients on
the use of herbs and supplements.
A)
Use of general healing techniques that involve plants, herbs, animals, ritual, ceremony, and
purification by a medicine
man or woman
B)
A system of postures, exercises, breathing techniques, and visualization that regulate balance
C)
The placement of thin, short, sterile needles at centers of nerve and vascular tissue along a
meridian
D)
Adjustment of the spine to accomplish proper alignment and to release pressure on a nerve
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3.
A Native American client informs the nurse that she practices shamanism. The nurse is aware
that shamanism is best
described as which of the following?
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Ans: A
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Shamanism is the use of general healing techniques that involve plants, herbs,
animals, ritual, ceremony, and purification by a medicine man or woman. Qi gong is
a system of postures, exercises, breathing techniques, and visualization that regulate
balance. Acupuncture is the placement of thin, short, sterile needles at centers of
nerve and
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vascular tissue along a meridian. Chiropractic medicine is the adjustment of the
spine to accomplish proper alignment and to release pressure on a nerve.
A)
Potential interactions with drugs
B)
The client’s cultural background and beliefs
C)
The client’s previous use of herbal supplements
D)
Pharmacological alternatives to herbs and supplements
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4.
Which of the following considerations should a nurse prioritize surrounding the use of herbs
and supplements by a
client?
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Ans: A
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Safety is paramount when herbs and supplements are being considered. One of the
most salient safety considerations surrounds the potential for drug interactions. This
consideration supersedes a client’s culture and previous use of herbs. It is beyond
most nurses’ scope of practice to recommend pharmacological alternatives to an
herb or supplement.
5.
A nurse practices holistic client care. Which of the following is a guiding principle of this
practice?
A)
Holism is focused on reductionism.
B)
All living organisms exist independently.
C)
The body is the sum of its parts.
D)
The body is a unified, dynamic whole.
Ans: D
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Feedback:
Holism is a theory and philosophy that focuses on connections and interactions
between parts of the whole. In contrast, the prevailing scientific approach has focused
on reductionism, the goal of which is to reduce all phenomena to the smallest possible
atom, particle, or interaction and make the body the sum of its parts.
A)
Reproductive hormones
B)
White blood cells
C)
Neuropeptides
D)
Pancreatic insulin
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6.
A young mother experiences nausea and diarrhea when stressed. What mind–body messenger
is believed to be
responsible for these responses?
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Ans: C
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The scientific field of psychoneuroimmunology studies neurochemicals, such as
neuropeptides, that are believed to be the messenger molecules that connect the body
and mind. Many neuropeptide receptor sites lie along the gastrointestinal tract; as a
result, people can experience a large variety of gastrointestinal symptoms in response
to emotional situations.
7.
A client with rheumatoid arthritis complains of soreness in his joints. Which of the following
homeopathic remedies
might the nurse recommend for this client?
A)
Arnica
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B)
Calendula
C)
Nux vomica
D)
Ignatia
Ans: A
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Arnica is a topical cream or oral pellets used for muscle soreness or bruising, joint
sprains, or strains. Calendula is an ointment applied to cuts, scrapes, burns, sores, and
nonfungal eruptions. Nux vomica is a remedy for stress, overwork, impatience, and
irritability. Ignatia is a remedy taken immediately following grief or loss and extreme
sadness.
A)
A human being is a closed energy system.
B)
A human being is bilaterally asymmetric.
C)
Illness is an imbalance in a person’s energy field.
D)
Humans do not have the ability to transform.
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8.
A nurse uses Therapeutic Touch to decrease a postoperative client’s nausea. Which of the
following is a principle of this
CAT modality?
Ans: C
Feedback:
Therapeutic Touch, the use of the hands on or near the body with the intent to help or
heal, is based on four principles. One of the principles is that illness is an imbalance
in a person’s energy field. Humans are open energy systems, are not bilaterally
asymmetric, and have the ability to transform.
What is the ultimate goal of increasing the parasympathetic system influence on the body
through relaxation or
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9.
meditation?
A)
Stimulate improved gastrointestinal function
B)
Increase cardiac output and blood pressure
C)
Facilitate respiratory function and cough
D)
Reduce the effects of stress on the body
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Ans: D
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Sympathetic system dominance is characterized by increased epinephrine levels in the
body, contributing to such stress- related conditions as hypertension, tachycardia, and
increased respiratory rate. Parasympathetic dominance has opposite effects, reducing
the effects of stress and stress-related illnesses on the body.
A)
Tongue and pulses
B)
Abdominal muscles and respirations
C)
Muscle tone and cranial nerves
D)
Vision and hearing
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10.
A nurse who is a traditional Chinese medicine practitioner is providing home care to a client
who also uses traditional
Chinese medicine for health care. What specific assessments would the nurse make?
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Ans: A
Feedback:
The goal of the TCM diagnostic process when assessing a client who practices
traditional Chinese medicine is to arrive at the pattern of disharmony that is being
manifested. The nurse would obtain a holistic health history and assess particular
parts of the client’s body, such as the tongue and pulses.
A client interested in acupuncture asks a nurse, “Just exactly what does it do?” What would
the nurse explain?
A)
“Acupuncture is based on a philosophy of laying on of hands.”
B)
“I don’t think it does anything, so I don’t know anything about it.”
C)
“It uses a manual process of adjusting the spine.”
D)
“It changes the flow of energy and helps healing.”
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Acupuncture is based on a belief in energy circuits that nourish and supply all cells
and organs of the body. By placing needles at particular acupoints, the flow of energy
is either increased or decreased, contributing to healing.
12.
A nurse is teaching a client about the proper use of herbs and supplements. Which statement
should be included?
A)
“Look on the Internet for the products you want to try.”
B)
“The federal government regulates supplements.”
C)
“It doesn’t matter how much you take.”
D)
“The product may take a longer time to be effective.”
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Ans: D
Feedback:
Information about the use of herbs and supplements includes the following: they should
come from a reliable source; are not regulated; can be toxic in higher-thanrecommended doses; and may take longer to produce a therapeutic effect than
allopathic preparations.
Which essential oil can be used during aromatherapy to treat nausea?
A)
Lavender
B)
Garlic
C)
Parsley
D)
Peppermint
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Ans: D
Essential oils commonly used in a health care setting to treat nausea include ginger
and peppermint. Garlic, lavender, and parsley are not used to treat nausea.
14.
A nurse is conducting a health history and asks the client about use of complementary and
alternative therapies (CAT) to
treat her chronic headaches. What response would require further questions?
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A)
“I practice meditation.”
B)
“I use relaxation to help me go to sleep.”
C)
“Each week, I have a total body massage.”
D)
“I take herbs to treat my headaches.”
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Ans: D
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Alternative therapies, such as herbs, are used most frequently for chronic conditions
such as depression or headaches. However, certain herbs may interact with each other
or with prescribed medications, causing negative effects. Forthis reason, the nurse
must ask further questions about the type of herb as well as the frequency of use.
What philosophy underlies the use of CAT?
A)
The mind, body, and spirit function as a unified whole.
B)
The mind and the body are separate and distinct.
C)
Parts of an organism rarely interact or change.
D)
Traditional medicine is most effective for chronic illnesses.
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Ans: A
Feedback:
A holistic philosophy underlies much of CAT. People have a mind, body, and spirit
that are connected and function as a unified whole. A change in any part of the
organism will be reflected in other parts.
16.
A nurse practitioner uses integrative care in his practice. What does this mean?
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A)
He uses allopathic medicine to treat all clients.
B)
He uses both allopathic medicine and CAT.
C)
The nurse uses CAT, a physician-prescribed medication.
D)
The nurse provides care for clients of all age groups.
Ans: B
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A health care provider who uses integrative care uses some combination of
allopathic medicine and CAT. Integrative care does not mean using allopathic
medicine to treat clients of all age groups; CAT is not a physician-prescribed
medication.
A nurse is practicing imagery to relieve stress. What might accompany the imagery to even
further promote relaxation?
A)
Bright lighting
B)
Bodywork techniques
C)
Talking on the phone
D)
Listening to
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17.
music Ans: D
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Feedback:
Music has demonstrated effectiveness in reducing pain, decreasing anxiety,
promoting relaxation, and distracting from unpleasant sensations. The other choices
are not appropriate for promoting relaxation.
A)
Therapeutic Touch
B)
Therapeutic massage
C)
Acupuncture
D)
Healing touch
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18.
A trained nurse uses the technique of “Rolfing” to break up tension in client body structures.
What type of CAT is being
used by this nurse?
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Therapeutic massage consists of an assortment of techniques that involve
manipulation of soft tissues of the body through pressure and movement, as well as a
variety of techniques such as Rolfing, shiatsu, Feldenkrais, Alexander, myofascial
release, and others. The goal is to break up tension held in body structures, promote
communication between mind–body structures, promote detoxification, and generally
improve body functioning.
19.
A client is very anxious before an invasive procedure. What CAM therapy would be most
helpful to assist in decreasing
anxiety?
A)
Meditation
B)
Chinese medicine
C)
Acupuncture
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D)
Herbs
Ans: A
Feedback:
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Meditation is a way to tune and train the mind, leading to greater efficiency in
everyday life. This will be most helpful in assisting this client to decrease the stress
level. Chinese medicine has a very broad base and includes meditation, acupuncture,
and herbs.
A client inquires about the use of herbal therapy. Which statement by the nurse is most
accurate?
A)
“All herbs are equal in purity, so purchase the cheapest brand.”
B)
“Herbs can have side effects and can interact with prescription medications.”
C)
“Be sure to pay attention to the packaging’s therapeutic and prevention information.”
D)
“It is best if you select a licensed herbalist as a practitioner.”
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Ans: B
Feedback:
It is important for clients to understand that herbs can have side effects and can
interact with prescription medications. Standardization of the herb’s constituents is
useful, but also limited because not all the compounds or the required levels are
known. Thus, the purity and dosage contents may not be equal between herbs. Herbal
products cannot make therapeutic and prevention claims. There is no current
licensing body for herbalists.
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Which of the following populations are more inclined to use CAT? Select all that apply.
A)
Women
B)
Adults aged 20 to 30
C)
People living in the east
D)
Former smokers
E)
Adults who are poor
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The 2007 survey found that in the United States, approximately 38% of adults (about
4 in 10) and approximately 12% of children (about 1 in 9) were using some form of
CAT in the 12 months before the survey. Consistent with results from the 2002
NHIS, in 2007, CAT use was more prevalent among women, adults age 30 to 69,
adults with higher levels of education, adults who were not poor, adults living in the
West, former smokers, and adults who were hospitalized in the last year.
A)
The wound is not approximated three days following surgery.
B)
The client reports pain as a “6” on a 0 to 10 pain scale.
C)
The client states that his anxiety following surgery has decreased.
D)
The client’s temperature has remained at or below 100.4ºF
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22.
The client is postoperative. The nurse is practicing healing touch with the client. Which of the
following would the nurse
evaluate as an expected outcome of healing touch?
Ans: C
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Healing touch may reduce the client’s anxiety, stimulate wound healing, relieve pain,
and promote health. The wound not being approximated, pain level of “6”, and
temperature of 100.4ºF are not expected outcomes of healing touch.
A)
echinacea?”
B)
goldenseal?”
C)
ginkgo biloba?”
D)
tumeric?”
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23.
The nurse is providing information about warfarin (Coumadin) to a client who takes herbal
products. The nurse states,
“Some herbs interfere with the effectiveness of warfarin. Do you take …
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Ginkgo biloba is an herb that affects platelet function. As a result, it should not be used with
warfarin.
24.
A client is taking ginkgo to improve her memory. In the education plan regarding this herb,
the nurse should include
which of the following?
A)
It may raise blood pressure.
B)
Avoid this herb if allergic to plants.
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C)
There is a possible sensitivity to light.
D)
Use caution if taking aspirin.
Ans: D
Feedback:
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Clients should be advised to use caution if taking aspirin in conjunction with ginkgo.
Ginseng may raise blood pressure. Avoid echinacea if allergic to plants in the daisy
family. Taking St. John’s wort may cause sensitivity to light.
A)
Complementary therapies
B)
Allopathic medicine
C)
Integrative care
D)
Holism
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25.
Which of the following is a theory and philosophy that focuses on connections and
interactions between parts of the
whole?
Feedback:
Holism is a theory and philosophy that focuses on connections and interactions
between parts of the whole. Complementary therapies can be used with traditional
medical interventions and complement them. Allopathic medicine is also known as
biomedicine. Integrative care uses a combination of allopathic medicine and
complementary and alternative therapies.
26.
The imbalance of which of the following can by the result of stress, lifestyle, and improper
diet?
A)
Doshas
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B)
Qi
C)
Chakras
D)
Aura
Ans: A
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Imbalance of the doshas can be caused by a number of factors, including stress,
lifestyle, and improper diet. Qi represents an invisible flow of energy that circulates
through plants, animals, and people. Chakras are concentrated areas of energy. An
aura consists of at least seven layers of energy that surround the body.
A)
Increasing numbers of acute conditions
B)
Dissatisfaction with conventional medicine
C)
Difficulty meeting rising health care costs
D)
Growth of culturally diverse groups
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27.
Which of the following would be the least consistent as a reason for the use of complementary
and alternative medicine
(CAM)?
Ans: A
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There are increasing numbers of people with chronic, incurable conditions. Reasons
to use CAM include dissatisfaction with conventional medicine, difficulty meeting
rising health care costs, and a growth of culturally diverse groups.
There are four primary scientific principles for therapeutic touch. Which of the following is
not one of these principles?
A)
A human being is bilaterally symmetrical.
B)
A human being is an open energy system.
C)
Distractions of modern life interfere with healing agents.
D)
Illness is an imbalance in an individual’s energy field.
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The four primary scientific principles of therapeutic touch are as follows: A human
being is bilaterally symmetrical. A human being is an open energy system. Illness is
an imbalance in an individual’s energy field. Human beings have natural abilities to
transform and transcend their conditions of living. The idea that distractions of
modern life interfere with healing agents is a Native American belief and is not
related to therapeutic touch.
29.
Which of the following is considered a holistic approach to food choices?
A)
The carbonation in soft drinks is beneficial to health.
B)
Vegetarian diets should be avoided because they limit options.
C)
Avoid eating foods with preservatives.
D)
Increase intake of natural sugar.
Ans: C
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Feedback:
A holistic approach to food includes avoiding eating foods with preservatives and
reducing or eliminating the amount of soft drinks consumed. It also recommends a
vegetarian diet and reducing intake of refined and natural sugars.
30.
A client informs a nurse practitioner that she takes the herb St. John’s wort for symptoms of
depression. The nurse
recognizes herbal therapy as belonging to which complementary and alternative therapy
(CAT) domain?
Biologically based practices
B)
Energy medicine
C)
Mind-body medicine
D)
Manipulative practices
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Biologically based practices include the use of herbs, animal-derived extracts,
vitamins, minerals, fatty acids, proteins, prebiotics and probiotics, whole diets, and
functional foods. Energy medicine involves the use of energy fields, such as magnetic
fields or biofields. Mind-body medicine uses techniques to enhance the mind’s ability
to affect bodily function and symptoms. Manipulative practices work with structures
and systems of the body.
31.
The nurse is slightly overweight and decides to take a holistic approach to losing weight. The
nurse does which of the
following? Select all that apply.
A)
Eliminates cola drinks
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B)
Decreases refined sugar
C)
Avoids foods with preservatives
D)
Adopts a vegatarian diet
E)
Substitutes aspartame for sugar
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Holistic approaches to food choices include eliminating cola drinks, reducing refined
sugar, and adopting a primarily vegetarian diet. Substituting aspartame for sugar is
not an example of a holistic approach to food choices.
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A woman age 35 years with a chronic disorder tells her nurse that she would be interested in
finding out about
complementary therapies that are available. What would be the nurse’s best response to this
client?
“It is best to stick with allopathic medicine.
B)
Complementary therapies are not available for your condition.
C)
Complementary therapies are not covered by your insurance plan.
D)
Complementary therapies are being used as an ‘answer’ to the problem of chronic illness.
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A)
Ans: D
Feedback:
Allopathic medical care is particularly effective when aggressive treatment is needed
in emergency or acute situations. However, allopathic medical care has not been
totally effective in dealing with chronic illness, a persistent problem. Increasingly,
complementary and alternative therapies are being used as an answer to the problem
of chronic illness.
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Which of the following complementary and alternative therapies is based on the “Law of
Minimal Dose”?
A)
Homeopathy
B)
Traditional Chinese
C)
qi Gong
D)
Ayurveda
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Samuel Hahnemann, a German physician, developed homeopathy approximately 200
years ago. The allopathic approach to dealing with illness is frequently to suppress
symptoms; for example, acetaminophen can be given to reduce a fever. In contrast,
homeopaths believe that when symptoms are suppressed in this manner, the condition
goes deeper into the body, making it ultimately more difficult to cure. Supporters of
homeopathy point to two unconventional theories: – “Like cures like”—the notion
that a disease can be cured by a substance that produces similar symptoms in healthy
people. – “Law of minimum dose”—the notion that the lower the dose of the
medication, the greater its effectiveness. Many homeopathic remedies are so diluted
that no molecules of the original substance remain.
34.
A nurse is teaching a client about holistic approaches to food choices. Which of the following
would the nurse
recommend?
A)
Consume more dairy products.
B)
Use artificial sweeteners instead of sugar.
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C)
Drink diet sodas instead of regular sodas.
D)
Reduce refined sugar intake.
Ans: D
Feedback:
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Some recommendations include reducing the amount of processed foods;
reducing/eliminating soft drinks (colas); reducing intake of refined and natural
sugars; reducing intake of artificial sweeteners, including aspartame; eating
organically grown foods; reducing intake of dairy products; and being aware of
genetically engineered, radiated food.
A)
Modern life facilitates healing agents.
B)
Healing takes time.
C)
Balancing yin and yang is important.
D)
Energy flows through meridians throughout the body.
Ans: B
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35.
The nurse caring for a Native American client plans care understanding that one belief of
Native American healing
practices is which of the following?
Feedback:
Native American healing practices are grounded in their cultural views. One
concept, identified in a study, is that healing takes time.
Chapter 30, Medications
1.
The nurse is preparing to administer a medication via a nasogastric tube. What guideline is
appropriate for the nurse to
follow when administering a drug via this route?
A)
Flush the tube with water between each drug administered.
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B)
Position the client supine prior to administering the drug.
C)
Administer the medication at a cold temperature.
D)
If connected to suction, do not reconnect to suction for five minutes after drug administration.
Ans: A
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Guidelines to consider when administering a drug via nasogastric tube include
positioning the client with the head of the bed elevated, administering the medication
at room temperature for the client’s comfort, flushing the tube with water between
each drug administered, and avoiding the use of suction for 20 to 30 minutes after the
drug is administered.
A)
Withhold the medication until the potential drug allergy has been addressed by the care team.
B)
Administer the medication and increase the frequency of assessments in the hours that follow.
C)
Substitute an antibiotic with similar action, but which is from a different drug family.
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2.
The medical chart of a newly admitted client notes a penicillin allergy, yet the
physician has just written an order for an antibiotic in the same drug family after
reviewing the client’s wound culture and sensitivity. How should the nurse
respond to this situation?
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D)
Discuss the severity, signs and symptoms of the drug allergy with the client in order to
ascertain the risks of
administration.
Ans: A
Feedback:
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Client safety is paramount, and the nurse has a responsibility to ensure that a potential
threat of harm is identified and dealt with promptly. It is beyond the nurse’s scope of
practice to independently substitute another drug, and it would be unsafe to
administer the drug in light of this revelation. The nurse would not administer the
drug even if the client stated that his or her allergy is mild.
Which of the following clients receives a drug that requires parenteral route?
A)
A woman who has been ordered intravenous antibiotics
B)
A woman who takes a diuretic pill each morning
C)
A man with emphysema who uses nebulized bronchodilators
D)
A man who has an antifungal ointment applied to his skin rash daily
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3.
Feedback:
The parenteral route includes such methods as intravenous administration and
injections. Pills are given by an oral route and a nebulizer is administered by the
pulmonary route. An ointment is a topical medication.
4.
A physician has ordered peak and trough levels of a medication. When would the nurse
schedule the trough level
specimen?
A)
Before administering the first dose
B)
Immediately after the first dose
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C)
30 minutes before the next dose
D)
24 hours after the last dose
Ans: C
Feedback:
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The trough level is the point when the drug is at its lowest concentration, and the
specimen is usually drawn in the 30- minute interval before the next dose. The peak
level, in contrast, is the highest plasma concentration of the drug.
A)
Peak level
B)
Trough level
C)
Half-life
D)
Therapeutic range
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5.
A client taking insulin has his levels adjusted to ensure that the concentration of drug in the
blood serum produces the
desired effect without causing toxicity. What is the term for this desired effect?
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A drug’s therapeutic range is the concentration of drug in the blood serum that
produces the desired effect without causing toxicity. The peak level, or highest
plasma concentration, of the drug should be measured when absorption is complete.
The peak level may be affected by factors that affect drug absorption as well as the
route of administration. The trough level is the point when the drug is at its lowest
concentration, and this specimen is usually drawn in the 30- minute interval before
the next dose. A drug’s half-life is the amount of time it takes for 50% of the blood
concentration of a drug to be eliminated from the body.
A)
Therapeutic effect
B)
Adverse effect
C)
Toxic effect
D)
Idiosyncratic effect
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6.
A client who is taking an oral narcotic for pain relief tells the nurse he is constipated. What is
this common response to
narcotics called?
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Ans: B
Although therapeutic effect is the desired outcome of medication administration,
sometimes adverse effects occur. Adverse effects (such as constipation from
narcotics) often are predictable and can usually be tolerated. Toxic effects (toxicities)
are specific groups of symptoms related to drug therapy that carry risk for permanent
damage or death. An idiosyncratic effect(sometimes called paradoxical effect) is any
unusual or peculiar response to a drug that may manifest itself by over-response,
under-response, or even the opposite of the expected response.
7.
A nurse is conducting an interview for a health history. In addition to asking the client about
medications being taken,
what else should be asked to assess the risk for drug interactions?
A)
The effects of prescribed medications
B)
Type and amount of foods eaten
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C)
Daily amount of intake and output
D)
Use of herbal supplements
Ans: D
Feedback:
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Herbal remedies can interact with prescribed medications. When asking a client if he
or she is taking any medications, the nurse should specifically ask if herbal
supplements are also being used.
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8.
A nurse is converting the dosage of a medication to a different unit in the metric system. The
medication label specifies
the drug as being 0.5 g per tablet. The order is for 500 mg. How many tablets will the nurse
give?
Feedback:
To convert in the metric system from a smaller unit to a larger unit, move the decimal point
three places to the right. As
0.5 g = 500 mg, the nurse would administer one tablet.
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A)
At the next scheduled medication time
B)
Immediately after the order is noted
C)
Not until verifying it with the client
D)
Whenever the client asks for it
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9.
A physician has ordered that a medication be given “stat” for a client who is having an
anaphylactic drug reaction. At
what time would the nurse administer the medication?
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Ans: B
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A stat order is a single order, and it is carried out immediately. This is a legal order.
The nurse would not wait until the next scheduled medication time or verify the
order with the client. With a p.r.n. order, the client receives medication when it is
requested or required.
What does the nurse do to verify an order for a medication listed on a medication
administration record (MAR)?
A)
Compare it with the original physician’s order.
B)
Ask another nurse what the drug is.
C)
Look up the drug in a textbook.
D)
Call the pharmacist for verification.
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10.
Ans: A
Feedback:
In many institutions, the medication order is copied onto the client’s medication
record. The nurse is responsible for checking that the medication order was
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transcribed correctly by comparing it with the original physician’s order.
A)
To prevent absorption in the mouth
B)
To prevent absorption in the esophagus
C)
To facilitate absorption in the stomach
D)
To prevent gastric irritation
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11.
A nurse is administering a medication that is formulated as enteric-coated tablets. What is the
rationale for not crushing
or chewing enteric-coated tablets?
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Ans: D
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Enteric-coated tablets are covered with a hard surface to impede absorption until the
tablet has left the stomach. Enteric- coated tablets should not be chewed or crushed
because the active ingredient of the drug is irritating to the gastric mucosa.
A)
Between the gum and the cheek
B)
In front of the teeth and gums
C)
On the front of the tongue
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12.
A nurse is administering a liquid medication to an infant. Where will the nurse place the
medication to prevent
aspiration?
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D)
Under the tongue
Ans: A
Feedback:
A dropper is used to give infants or very young children liquid medications while
holding them in a sitting or semisitting position. The medication is placed between
the gum and the cheek to prevent aspiration.
A)
“You can identify your medications by their color.”
B)
“I have written the names of your drugs with times to take them.”
C)
“You won’t forget a medication if you count them every day.”
D)
“Don’t worry if the label comes off; just look at the shapes.”
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13.
A nurse is teaching an older adult at home about taking newly prescribed medications. Which
information would be
included?
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Ans: B
Feedback:
Teach clients the names of drugs rather than distinguishing drugs by color.
Manufacturers may vary the color of generic drugs, and the visual changes associated
with aging may make it more difficult to identify medications by color.
Medications should not be identified by counting or by shapes.
14.
A student nurse is administering medications through a nasogastric tube connected to
continuous suction. How will the
student do this accurately?
A)
Briefly disconnect tubing from the suction to administer medications, then reconnect.
B)
Realize this can’t be done, and document information.
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C)
Disconnect tubing from the suction before giving drugs, and clamp tubing for 20 to 30
minutes.
D)
Leave the suction alone and give medications orally or rectally.
Ans: C
Feedback:
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To administer medications to clients with a nasogastric tube connected to continuous
suction, disconnect the tubingfrom the suction, administer the medications one at a
time, and then clamp the tubing for 20 to 30 minutes after administration to allow
absorption.
What would a nurse instruct a client to do after administration of a sublingual medication?
A)
“Take a big drink of water and swallow the pill.”
B)
“Try not to swallow while the pill dissolves.”
C)
“Swallow frequently to get the best benefit.”
D)
“Chew the pill so it will dissolve faster.”
Ans: B
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15.
Feedback:
Sublingual and buccal medications should not be swallowed, but rather held in place
so that complete absorption takes place.
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A)
All needles for parenteral injection are the same gauge.
B)
The gauge will depend on the length of the needle.
C)
Ask the client what size needle is preferred.
D)
Gauges range from 18 to 30, with 18 being the largest.
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16.
A nurse is administering an intramuscular injection of a viscous medication using the
appropriate-gauge needle. What
does the nurse need to know about needle gauges?
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The gauge is determined by the diameter of the needle and ranges from 18 to 30. As
the diameter of the needle increases, the gauge number decreases (an 18-gauge needle
is, therefore, larger than a 30-gauge needle). A viscous medication requires a largergauge needle for injection.
A nurse has administered an intramuscular injection. What will the nurse do with the syringe
and needle?
A)
Recap the needle; place it in a puncture-resistant container.
B)
Do not recap the needle; place it in a puncture-resistant container.
C)
Break off the needle, place it in the barrel, and throw it in the trash.
D)
Take off the needle and throw the syringe in the client’s trash can.
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17.
Ans: B
Feedback:
After use, needles and syringes are placed in a puncture-resistant container without
being recapped. This prevents needlestick injuries, because most occur during
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recapping.
A)
10-mL syringe, 3-inch 18-gauge needle
B)
5-mL syringe, 2-inch 20-gauge needle
C)
Insulin syringe, 1-inch 16-gauge needle
D)
Tuberculin syringe, 1/2-inch 26-gauge needle
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18.
A clinic nurse is preparing for a tuberculosis screening. Knowing the injections will be
administered intradermally, what
size needles and syringes will the nurse prepare?
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Ans: D
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Equipment used for an intradermal injection includes a tuberculin syringe calibrated
in tenths and hundredths of a milliliter. A quarter-inch to half-inch 26- or 27-gauge
needle is used.
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19.
A nurse is caring for a client in the nursing unit when the physician, during the rounds,
prescribes a medication for the
client. What appropriate action should the nurse take to ensure the accuracy of the verbal
medication order?
A)
Ask the physician to repeat the dosage.
B)
Ask the physician to spell out the medication name.
C)
Ask a second nurse to listen for accuracy.
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D)
Ask the physician to write out the order.
Ans: D
Feedback:
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To maintain the accuracy of a verbal order, the nurse should tactfully ask the
physician for a written order. When obtaining phone orders, it is important to repeat
the dosages of medications and to spell medication names for confirmation of
accuracy. Some nurses may ask a second nurse to listen to a telephone order on an
extension.
A)
Ensures that the right medication is given at the right time by the right route
B)
Complies with the medical order and ensures that the right dose is given
C)
Ensures that the medication has been administered to the right client
D)
Demonstrates timely administration and compliance with the medical order
Ans: A
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20.
A nurse at the health care facility is preparing the medication dosage for a client.
Why should the nurse read and compare the label on the medication with the MAR
at least three times (before, during, and after) while preparing the
medication for administration?
Feedback:
When preparing the medications for administration, the nurse reads and compares the
label on the medication with the MAR at least three times. This is to ensure that the
right medication is given at the correct time, and by the correct route. The nurse
calculates the doses to comply with the medical order and ensure that the right dose
is given. Before administration, the nurse identifies the client by checking the
wristband or asking the client’s name. This is to ensure that the medication is given
to the right person. The nurse should plan to administer the medications within 30 to
60 minutes of their scheduled time, which demonstrates timely administration and
compliance with the medical order.
A client with allergy has been advised to have an allergy test. The nurse needs to administer
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an injection to the client for
allergy testing. Which of the following injection routes is most suitable for allergy testing?
A)
Subcutaneous
B)
Intramuscular
C)
Intradermal
D)
Intravenous
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Intradermal injection routes are commonly used for tuberculin tests and allergy
testing because they are administered between the layers of the skin. A subcutaneous
injection is not suitable because it is administered more deeply than an intradermal
injection; whereas, an intramuscular injection is administered in one muscle or
muscle group. Intravenous injection is also not suitable because it is instilled into
veins.
A)
180-degree angle
B)
90-degree angle
C)
45-degree angle
D)
10-degree angle
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22.
A nurse needs to administer an intradermal tuberculin skin test injection to a client. Which of
the following is the most
suitable angle when administering an intradermal injection?
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Ans: D
Feedback:
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When administering an intradermal injection, the nurse should hold the syringe
almost parallel to the skin at a 10-degree angle with the bevel pointing upward. This
facilitates delivering the medication between the layers of the skin and advances the
needle to the desired depth. A nurse administers a subcutaneous injection at a 45degree angle or a 90- degree angle to reach the subcutaneous level of tissue,
depending on the length of the needle. The nurse will not be able to insert the
injection if it is held at a 180-degree angle.
A)
In a double-locked drawer
B)
In a single container
C)
In a self-contained packet
D)
In disguised containers
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23.
A nurse needs to administer a prescribed dose of a narcotic medication to a client with acute
neck pain. Which of the
following precautions should the nurse take when storing narcotic medications?
Feedback:
The nurse should place narcotic drugs in a double-locked drawer. Narcotics are
controlled substances, meaning that federal laws regulate their possession and
administration. Health care facilities keep narcotics in a double-locked drawer, box,
or room on the nursing unit. A narcotic drug may not be placed in a single container,
self-contained packet, or in disguised containers.
24.
A nurse at a health care facility administers a prescribed drug to a client and does not
record doing so in the medical administration record. The nurse who comes during
the next shift, assuming that the medication has not been administered, administers
the same drug to the client again. The nurse on the previous shift calls to inform the
health care facility that the administration of the drug to this client in the earlier shift
was not recorded. What should the nurse
on duty do immediately upon detection of the medication error?
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A)
Report the incident to the physician.
B)
Report the incident to the supervising nurse.
C)
Check the client’s condition.
D)
Fill in the accident report sheet.
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Ans: C
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On detection of the medication error, the nurse should immediately check the client’s
condition. When medication errors occur, nurses have an ethical and legal
responsibility to report them to maintain the client’s safety. As soon as the nurse
recognizes an error, he or she should check the client’s condition and report the
mistake to the prescriber and supervising nurse immediately. Health care agencies
have a form for reporting medication errors called an incident sheet or accident sheet.
A)
Shaking the contents of the ointment
B)
Applying inunction with a cotton ball
C)
Rubbing the ointment into the skin
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25.
A client with dry skin has been prescribed inunction. Which of the following should the nurse
do to promote absorption
of the ointment?
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D)
Warming the inunction before application
Ans: C
Feedback:
In order to promote absorption, the nurse should rub the ointment into the client’s
skin. Shaking the contents would mix the contents uniformly, whereas applying the
with a cotton ball would distribute the substance over a wide area.
Warming the ointment before application would provide comfort.
A)
Manipulation of the client’s ear to straighten the auditory canal
B)
Dilution of the medication drops before instilling in the client’s ear
C)
Position in which the client remains until medication reaches the eardrum
D)
Amount of time before instilling medication in the client’s opposite ear
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26.
A nurse at a health care facility has to instill ear drops in a client. The nurse knows that which
of the following
techniques varies for an adult and child client?
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Ans: A
Feedback:
The nurse should be aware that the method of manipulation of the client’s ear to
straighten the auditory canal varies between an adult and child. In a young client, the
nurse pulls the ear down; in an adult client, the nurse pulls the ear up and back. The
medication is not diluted; the number of medication drops instilled is as per the
physician’s prescription, and does not depend on the client’s age. The position in
which the client remains until the medication reaches the eardrum, and the amount of
time before instilling medication in the client’s opposite ear, does not differ with the
age of the client.
27.
A nurse is showing an older adult client the correct method of self-administering an insulin
injection at home. Which of
the following points should the nurse tell the client in order to avoid lipoatrophy and
lipohypertrophy?
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D)
Warming the inunction before application
A)
Change the needle daily with each injection.
B)
Rotate the site with each injection.
C)
Apply local anesthetic to the injection site.
D)
Massage the injection site for 10 minutes.
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Ans: B
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The nurse should tell the client to rotate the injection site each time an insulin
injection is administered to prevent lipoatrophy and lipohypertrophy. In case of an
insulin injection, the needle need not be changed daily but rather after a specific
period specified by the manufacturer on the injection. Local anesthetic need not be
applied to the injection site when administering insulin as the needle used causes
very little discomfort. There is also no need to massage the injection site when
insulin is administered. Massaging is contraindicated when heparin is administered,
because this can increase the tendency for local bleeding.
A)
Type of needle to be used for withdrawal
B)
Directions for administering the drug
C)
Best site for administering the drug
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28.
A nurse should read the instructions stated on a vial container before reconstituting it and
administering it to a client.
Which of the following instructions are stated on the label of a vial container?
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D)
Amount of diluent to be added
Ans: D
Feedback:
om
When reconstitution is necessary, the drug label lists instructions such as the amount
of diluent to be added and the type of diluent to be used, but not the type of needle.
The label states the dosage per volume after reconstitution, not the best site for
administering the drug after the reconstitution. It also states the directions for storing
the drug, not thedirections for administering the drug to a client.
A)
To prevent needle-stick injuries
B)
To ensure the accuracy of landmarking
C)
To facilitate blood circulation at injection site
D)
To avoid instilling medication within the muscle
Ans: D
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29.
A nurse is bunching the tissue of a client when administering a subcutaneous injection to that
client. The nurse knows
that which of the following is the reason for bunching when injecting subcutaneously?
Feedback:
Nurses bunch tissue between the thumb and fingers before administering the injection
to avoid instilling medication within the muscle. Bunching does not prevent needlestick injuries, it does not facilitate blood circulation at the injection site, nor does it
ensure the accuracy of landmarking.
30.
A)
A client diagnosed with anemia is receiving a blood transfusion. The client develops urticaria
accompanied by wheezing
and dyspnea not long after the transfusion starts. The nurse interprets this as indicative of
which of the following?
Allergic reaction
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B)
Side effect
C)
Toxicity
D)
Antagonism
Ans: A
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With urticaria, hives, wheezing, and dyspnea are the symptoms of severe allergic
reaction, which is due to an anaphylactic reaction. Minor adverse effects are called
side effects. Many side effects are essentially harmless and can be ignored. Toxicity
results from overdosage or buildup of medication in the blood due to impaired
metabolism and excretion. Antagonism is a drug interaction by which drug effects
decrease.
Which medication system allows for client independence?
A)
Unit dose system
B)
Self-administered medication system
C)
Automated medication-dispensing system
D)
Bar Code Medication Administration
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31.
Ans: B
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The self-administered system allows the client independence and responsibility. It
also allows nursing supervision, education, and evaluation for client compliance and
safety medication management prior to facility discharge.
A physician writes an order for ampicillin 1 gram every 6 hours for a client. What is missing
in this order?
A)
Time
B)
Amount
C)
Route
D)
Frequency
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The medication order does not identify a route.
What is the name of the process by which a drug moves through the body and is eventually
eliminated?
A)
Pharmacology
B)
Pharmacotherapeutics
C)
Pharmacokinetics
D)
Pharmacodynamics
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33.
Ans: C
Feedback:
Pharmacokinetics is the process by which a drug moves through the body and is eventually
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eliminated.
Medications administered that are renal toxic should have frequent assessments of which
blood values?
A)
AST and ALT
B)
BUN and creatinine
C)
WBC and platelets
D)
RBC and differential
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Ans: B
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If medications are known to cause kidney dysfunction, kidney function tests (serum
creatinine, blood urea nitrogen) should be frequent.
A)
Medication
B)
Client
C)
Prescribing physician
D)
Pharmacy
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35.
The “Rights of Medication Administration” help to ensure accuracy when administering
medications. Which of the
following represent these five rights? Select all that apply.
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E)
Dosage
F)
Route
Ans: A, B, E, F
Feedback:
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To prevent medication errors, always ensure that the: (1) Right medication is given to
the (2) right client in the (3) right dosage through the (4) right route at the (5) right
time.
Chapter 31, Perioperative Nursing
A)
Inform the physician that it is his or her responsibility to obtain the signature.
B)
Obtain the signature and ask another nurse to cosign the signature.
C)
Inform the physician that the nurse manager will need to obtain the signature.
D)
Call the house officer to obtain the signature.
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1.
The nurse is preparing to send a client to the operating room for an exploratory
laparoscopy. The nurse recognizes that there is no informed consent for the procedure
on the client’s chart. The nurse informs the physician who is performing the
procedure. The physician asks the nurse to obtain the informed consent signature
from the client. What is the nurse’s
best action to the physician’s request?
Ans: A
Feedback:
The responsibility for securing informed consent from the client lies with the person
who will perform the procedure. The nurse’s best action is to inform the physician
that it is his or her responsibility to obtain the signature.
2.
Upon assessment, a client reports that he drinks five to six bottles of beer every evening after
work. Based upon this
information, the nurse is aware that the client may require which of the following?
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A)
Larger doses of anesthetic agents and larger doses of postoperative analgesics
B)
Larger doses of anesthetic agents and lower doses of postoperative analgesics
C)
Lower doses of anesthetic agents and lower doses of postoperative analgesics
D)
Lower doses of anesthetic agents and larger doses of postoperative analgesics
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Ans: A
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Clients with a large habitual intake of alcohol require larger doses of anesthetic
agents and postoperative analgesics, increasing the risk for drug-related
complications.
A)
Cardiac problems
B)
Infection
C)
Bleeding and anemia
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3.
The telemetry unit nurse is reviewing laboratory results for a client who is scheduled
for an operative procedure later in the day. The nurse notes on the laboratory report
that the client has a serum potassium level of 6.5 mEq/L, indicative of hyperkalemia.
The nurse informs the physician of this laboratory result because the nurse recognizes
hyperkalemia
increases the client’s operative risk for which of the following?
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D)
Fluid imbalances
Ans: A
Feedback:
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Hyperkalemia or hypokalemia increases the client’s risk for cardiac problems. A
decrease in the hematocrit and hemoglobin level may indicate the presence of anemia
or bleeding. An elevated white blood cell count occurs in the presence of infection.
Abnormal urine constituents may indicate infection or fluid imbalances.
A)
Before the pain becomes severe
B)
When the client experiences a pain rating of “10” on a 1-to-10 pain scale
C)
When there is no pain, but it is time for the medication to be administered
D)
After the pain becomes severe and relaxation techniques have failed
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4.
The nurse is providing education to a client regarding pain control after surgery. What time
does the nurse inform the
client is the best time to request pain medication?
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Feedback:
If a pain medication is ordered p.r.n., the client should be instructed to ask for the
medication before the pain becomes severe.
5.
A client returning to the floor after orthopedic surgery is complaining of nausea. The nurse is
aware that an appropriate
intervention is to do which of the following?
A)
Avoid strong smelling foods.
B)
Provide clear liquids with a straw.
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C)
Avoid oral hygiene until the nausea subsides.
D)
Hold all medications.
Ans: A
Feedback:
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Nursing care for a xlient with nausea includes avoiding strong smelling foods,
providing oral hygiene, administering prescribed medications (especially medications
ordered for nausea and vomiting), and avoiding use of a straw.
A)
“I’ll practice these now and try to start them as soon as I can after my surgery.”
B)
“I’ll try to do these lying on my stomach so that I can bend my knees more fully.”
C)
“I’ll make sure to do these, as long as my doctor doesn’t tell me to stay on bed rest after my
operation.”
D)
“I’m pretty sure my stomach muscles are strong enough to lift both of my legs off the bed at
the same time.”
Ans: A
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6.
In order to prevent the possibility of venous stasis, a nurse is teaching a surgical client how to
perform leg exercises.
Which of the client’s following statements indicates a sound understanding of leg exercises?
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Leg exercises should be begun as soon as possible after surgery, unless
contraindications exist. Bed rest does not preclude the performance of leg exercises
and the legs should be lifted individually, not simultaneously. The client should
perform leg exercises in a semi-Fowler’s, not prone, position.
A)
Urgent
B)
Elective
C)
Emergency
D)
Emergent
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7.
A female client is scheduled for liposuction surgery to reduce her weight. Based on urgency,
how is this surgery
classified?
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A liposuction procedure is classified as elective surgery, in which the procedure is
preplanned and based on the client’s choice. Other classifications are urgent (surgery
is necessary for the client’s health but not an emergency) and emergency (the
surgery must be done immediately to preserve life, body part, or body function).
8.
A client scheduled for major surgery will receive general anesthesia. Why is inhalation
anesthesia often used to provide
the desired actions?
A)
Rapid excretion and reversal of effects
B)
Safe administration in the client’s own room
C)
Involves only the respiratory system and skin
D)
Slow onset of action and maintains reflexes
Ans: A
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Feedback:
General anesthesia involves the administration of drugs by inhalation and intravenous
routes to produce central nervous system depression. Inhalation anesthesia is often
used because it has the advantage of rapid excretion and reversal of effects.
A)
“You will be asleep and won’t be aware of the procedure.”
B)
“You will be asleep but may feel some pain during the procedure.”
C)
“You will be awake but will not be aware of the procedure.”
D)
“You will be awake and will not have sensation of the procedure.”
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9.
A nurse is educating a client about regional anesthesia. Which of the following statements is
accurate about this type of
anesthesia?
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Ans: D
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Regional anesthesia occurs when an anesthetic agent is injected near a nerve or nerve
pathway in or around the operative site, inhibiting the transmission of sensory stimuli
to central nervous system receptors. The client remains awake but loses sensation in
a specific area or region of the body.
10.
A nurse has been asked to ensure informed consent for a surgical procedure. What might be a
role of the nurse?
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A)
Securing informed consent from the client
B)
Signing the consent form as a witness
C)
Ensuring the client does not refuse treatment
D)
Refusing to participate based on legal guidelines
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Ans: B
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The responsibility for securing informed consent from the client lies with the person
who will perform the procedure, usually the physician. The nurse may sign as a
witness, signifying that the client signed the consent form without coercion, and was
alert and aware of the act.
A)
Discuss with and document the wishes of the client and family
B)
Administer the ordered oral and intravenous preoperative medications
C)
Notify the physician after completion of the surgical procedure
D)
Verbally report the client’s wishes to the operating room supervisor
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11.
A client, scheduled for open-heart surgery, tells the nurse he does not want to be “saved” if he
dies during surgery. What
should the nurse do next?
Ans: A
Feedback:
Advance directives allow the client to specify instructions for health care treatment
if unable to communicate these wishes during or after surgery. It is important for
the nurse to discuss and document exact do not resuscitate(DNR) wishes of the
client and family before surgery.
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A)
Increased vascular rigidity
B)
Diminished chest expansion
C)
Lower total blood volume
D)
Decreased peripheral circulation
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12.
An operating room nurse is preparing for a surgical procedure on an infant. The nurse’s
perioperative care is based on
what physiologic factor that puts infants at greater risk from surgery than adults?
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Ans: C
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Infants are at a greater risk from surgery as a result of various physiologic factors. A
major factor is that the infant has a lower total blood volume, making even a small loss
of blood a serious consideration because of the risk for dehydration and the inability
to respond to the need for increased oxygen during surgery.
A)
Perform sterile dressing changes each morning.
B)
Administer pain medications as needed.
C)
Conduct a head-to-toe assessment each shift.
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13.
After conducting a preoperative health assessment, the nurse documents that the
client has physical assessments supporting the medical diagnosis of emphysema.
Based on this finding, what postoperative interventions would be
included on the plan of care?
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D)
Monitor respirations and breath sounds.
Ans: D
Feedback:
Respiratory disorders, including emphysema, increase the risk for respiratory
depression from anesthesia as well as postoperative pneumonia and atelectasis.
A)
Risk for Aspiration
B)
Risk for Imbalanced Body Temperature
C)
Risk for Infection
D)
Risk for Falls
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14.
A preoperative assessment finds a client to be 75 pounds overweight. The client is to have
abdominal surgery. What
nursing diagnosis would be appropriate based on the client’s weight?
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Ans: C
Fatty tissue in obese clients has a poor blood supply and, therefore, has less resistance
to infections. Postoperative complications of delayed wound healing, wound
infection, and disruption of the wound are more common in obese clients.
15.
Which of the following interventions is of major importance during preoperative education?
A)
Performing skills necessary for gastrointestinal preparation
B)
Encouraging the client to identify and verbalize fears
C)
Discussing the site and extent of the surgical incision
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D)
Telling the client not to worry or be afraid of surgery
Ans: B
Feedback:
A surgical procedure causes anxiety and fear. The nurse should encourage the client
to identify and verbalize fears; often simply talking about fears helps to diminish their
magnitude.
A)
Nothing; potassium levels have no influence on surgical outcome.
B)
Include the information in the postoperative end of shift report.
C)
Document the data and notify the physician who will do the surgery.
D)
Ask the client and family members why the potassium is low.
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16.
A nurse is reviewing results of preoperative screening tests and notes the client’s potassium
level is dangerously low.
What should the nurse do next?
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Ans: C
Feedback:
Either high or low levels of potassium put the surgical client at increased risk for
cardiac problems during and after surgery. The nurse’s role includes recording the
data in the client’s record and reporting abnormal findings.
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A nurse is educating a surgical client on postoperative p.r.n. pain control. Which of the
following should be included?
A)
“We will bring you pain medications; you don’t need to ask.”
B)
“Even if you have pain, you may get addicted to the drugs.”
C)
“You won’t have much pain so just tough it out.”
D)
“You need to ask for the medication before the pain becomes severe.”
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If medication for pain is ordered p.r.n., there is a time restriction between doses. The
client needs to ask for the medication and should do so before the pain becomes
severe.
A)
“Hold a pillow or folded bath blanket over the incision.”
B)
“Get up and walk before you try to cough.”
C)
“It would be best if you do not cough until you feel better.”
D)
“When you cough, cover your nose and mouth with a tissue.”
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18.
A nurse is educating a preoperative client on how to cough effectively. What can the nurse tell
the client to do to
facilitate coughing?
Ans: A
Feedback:
Because postoperative coughing is often painful, the client should be taught how to
splint the incision by supporting it with a pillow or folded bath blanket.
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A)
Surgical clients routinely are given a cleansing enema.
B)
Cleansing enemas are given before surgery at the client’s request.
C)
There will be less flatus and discomfort postoperatively.
D)
Peristalsis does not return for 24 to 48 hours after surgery.
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19.
A cleansing enema is ordered for a client who is scheduled to have colon surgery. What is the
rationale for this
procedure?
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Ans: D
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If the client is scheduled for gastrointestinal tract surgery, a cleansing enema is
usually ordered. Peristalsis does not return for 24 to 48 hours after the bowel is
handled, so preoperative cleansing helps decrease postoperative constipation.
A)
To determine the length of time to recover from anesthesia
B)
To use intraoperative data as a basis for comparison
C)
To focus on cardiovascular data and findings
D)
To prevent complications from anesthesia and surgery
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20.
A nurse working in a PACU is responsible for conducting assessments on immediate
postoperative clients. What is the
purpose of these assessments?
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Ans: D
Feedback:
Immediate postoperative care in the PACU involves assessing the postoperative client
with emphasis on preventing complications from the surgery.
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21.
A nurse is providing ongoing postoperative care to a client who has had knee surgery. The
nurse assesses the dressing
and finds it saturated with blood. The client is restless and has a rapid pulse. What should the
nurse do next?
Document the data and apply a new dressing.
B)
Apply a pressure dressing and report findings.
C)
Reassure the family that this is a common problem.
D)
Make assessments every 15 minutes for four hours.
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A)
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Ans: B
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Feedback:
Hemorrhage is an excessive internal or external loss of blood. Common indications of
hemorrhage include a rapid, thready pulse. If bleeding occurs, the nurse should apply
a pressure dressing to the site, report findings to the physician, and be prepared to
return the client to the operating room if bleeding cannot be stopped or is massive.
22.
A postoperative home care client has developed thrombophlebitis in her right leg. What
category of medications will
probably be prescribed for this cardiovascular complication?
A)
Anticoagulants
B)
Antibiotics
C)
Antihistamines
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D)
Antigens
Ans: A
Feedback:
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Thrombophlebitis is an inflammation of a vein associated with thrombus formation.
Thrombophlebitis from venous stasis is most commonly seen in the legs of
postoperative clients. Nursing interventions include administering ordered
medications, most often anticoagulants.
A)
It increases blood flow to the heart.
B)
The client will be more comfortable and have less pain.
C)
It facilitates nursing assessments of skin color and temperature.
D)
It promotes full aeration of the lungs.
Ans: D
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23.
A student is assessing a postoperative client who has developed pneumonia. The plan of care
includes positioning the
client in the Fowler’s or semi-Fowler’s position. What is the rationale for this position?
Feedback:
Pneumonia may occur in the postoperative client from aspiration, immobilization,
depressed cough reflex, infection, increased secretions from anesthesia, or
dehydration. Nursing interventions include positioning the client in the Fowler or
semi-Fowler position to promote full aeration of the lungs.
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24.
A young woman has been in an automobile crash that resulted in an amputation of her left
lower leg. She verbalizes
grief and loss. What knowledge by the nurse is used to provide interventions to help the client
cope?
The client should be grateful to be alive.
B)
This is a normal, appropriate response.
C)
This is an abnormal, inappropriate response.
D)
Tissue healing will help the client adapt.
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A)
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Ans: B
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Many surgical clients have the same reaction to loss of a body part as they would to a
death. A surgical client’s grief is a normal, appropriate response. The nurse must be
aware of the client’s needs and provide interventions to meet those needs in coping
with change.
A)
The client is not allowed to drive a car home.
B)
If the client is not dizzy, driving a car is allowed.
C)
Only adults over the age of 25 may drive home.
D)
None; this is not necessary information.
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25.
A nurse in an outpatient surgical center is teaching a client about what will be necessary for
discharge to home. What
information should the nurse include about transportation?
Ans: A
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After outpatient surgery, clients may go home when they are no longer dizzy or
drowsy, have stable vital signs, and have voided. Clients are not allowed to drive a
car home.
Which of the following interventions are recommended guidelines for meeting client
postoperative elimination needs?
A)
Assess abdominal distention, especially if bowel sounds are audible or are low pitched.
B)
Assess for the return of peristalsis by auscultating bowel sounds every four hours when the
client is awake.
C)
Encourage food and fluid intake when ordered, especially dairy products and low-fiber foods.
D)
Assess for bladder distention by Palpating below the symphysis pubis if the client has not
voided within eight hours after
surgery.
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26.
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Ans: B
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Assess for the return of peristalsis by auscultating bowel sounds every four hours
when the client is awake. Assess abdominal distention, especially if bowel sounds
are inaudible or are high pitched. Encourage food and fluid intake when ordered,
especially fruit juices and high-fiber foods. Assess for bladder distention by
palpating above the symphysis pubis if the client has not voided within eight hours
after surgery.
27.
A nurse is assisting a postoperative client with deep-breathing exercises. Which of the
following is an accurate step for
this procedure?
A)
Place the client in prone position, with the neck and shoulders supported.
B)
Ask the client to place the hands over the stomach, so he or she can feel the chest rise as the
lungs expand.
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C)
D)
Ask the client to exhale rapidly and completely, and inhale through the nose rapidly and
completely.
Ask the client to hold his or her breath for three to five seconds and mentally count “one, one
thousand, two, one
thousand” and so forth.
Ans: D
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The nurse should place the client in semi-Fowler’s position, with the neck and
shoulders supported, and ask the client to place the hands over the rib cage, so he or
she can feel the chest rise as the lungs expand. Then, ask the patient to exhale gently
and completely, inhale through the nose gently and completely, hold his or her breath
for three to five seconds, and mentally count “one, one thousand, two, one thousand”
etc., then exhale as completely as possible through the mouth with lips pursed (as if
whistling).
A)
Administer prescribed pain medication just before coughing.
B)
Ask the client to drink plenty of water before coughing.
C)
Ask the client to lie in a lateral position when coughing.
D)
Administer prescribed pain medication 30 minutes before deliberately attempting to cough.
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28.
A client with abdominal incisions experiences excruciating pain when he tries to cough. What
should the nurse do to
reduce the client’s discomfort when coughing?
Ans: D
Feedback:
Coughing is painful for clients with abdominal or chest incisions. Administering pain
medication approximately 30 minutes before coughing, or splinting the incision
when coughing, can reduce discomfort. Making the client lie in a lateral position or
asking the client to drink plenty of water is not helpful because it will make
breathing and coughing even more difficult for the client.
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A)
Client can respond verbally despite physical immobility.
B)
Client can tolerate long therapeutic surgical procedures.
C)
Client is relaxed, emotionally comfortable, and conscious.
D)
Client’s consciousness level can be monitored by equipment.
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29.
A physician has ordered a nurse to administer conscious sedation to a client. Which of the
following is possible after
administering conscious sedation to a client?
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Ans: C
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Conscious sedation refers to a state in which the client is sedated in a state of
relaxation and emotional comfort, but is not unconscious. The client is free of pain,
fear, and anxiety and can tolerate unpleasant diagnostic and short therapeutic surgical
procedures, such as an endoscopy or bone marrow aspiration. The client can respond
verbally and physically. However, no equipment can replace a nurse’s careful
observations for monitoring clients.
A)
Ensure the safe recovery of surgical clients.
B)
Monitor the client for complications.
C)
Prepare a room for the client’s return.
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30.
A nurse is taking care of a client during the immediate post-operative period. Which of the
following duties performed
during the immediate post-operative period is most important?
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D)
Assess the client’s health constantly.
Ans: B
Feedback:
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The immediate post-operative period refers to the first 24 hours after surgery. During
this time, the nurse monitors the client for complications as he or she recovers from
anesthesia. Once the client is stable, the nurse prepares a room for the client’s return
and assesses the client to prevent or minimize potential complications. The nurse
ensures the safe recovery of the client after the client has stabilized.
A)
Obtain a signature on the consent form.
B)
Review the surgical checklist.
C)
Conduct a nursing assessment.
D)
Reduce the dosage of toxic drugs.
Ans: C
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31.
A nurse is caring for a client who is scheduled to undergo a breast biopsy. Which of the
following major tasks does the
nurse perform immediately during the pre-operative period?
Feedback:
During the immediate pre-operative period, the nurse conducts a nursing assessment.
Nurses obtain the signature of the client, nearest blood relative, or someone with
durable power of attorney before the administration of any pre-operative sedatives.
They also administer medications as ordered by the physician regardless of their
toxicity. They assist the client with psychosocial preparation and complete the
surgical checklist, which is reviewed by the operating room personnel.
32.
A nurse is assisting a physician during a cesarean section for a client. The client is
administered epidural anesthesia.
Which of the following is an advantage of epidural anesthesia?
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A)
It counteracts the effects of conscious sedation.
B)
It decreases the risk of gastrointestinal complications.
C)
It prevents clients from remembering the initial recovery period.
D)
It acts on the central nervous system to produce loss of sensation.
Ans: B
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Epidural anesthesia is a regional anesthesia administered to a client before surgery; it
decreases the risk of gastrointestinal complications in clients. Reversal drugs are
medications that counteract the effects of those used for conscious sedation. General
anesthesia acts on the central nervous system to produce loss of sensation; it prevents
clients from remembering their initial recovery period.
Which of the following nursing interventions occurs in the postoperative phase of the surgical
experience?
A)
Airway/oxygen therapy/pulse oximetry
B)
Teaching deep breathing exercises
C)
Reviewing the meaning of p.r.n. orders for pain medications
D)
Putting in IV lines and
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33.
administering fluids Ans: A
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Feedback:
Airway/oxygen therapy/pulse oximetry occur in the postanesthesia unit in the
postoperative phase. Teaching deep- breathing exercises and reviewing the meaning
of p.r.n. orders for medications occur in the preoperative phase. Putting in IV lines
and administering fluids occurs in the intraoperative phase.
A)
Force fluids for an adult client who has a urine output of less that 30 mL per hour.
B)
If client is febrile within 12 hours of surgery, notify the physician immediately.
C)
If the dressing was clean but now has a large amount of fresh blood, remove the dressing and
reapply it.
D)
If vital signs are progressively increasing or decreasing from baseline, notify the physician of
possible internal bleeding.
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34.
Which statement accurately represents a recommended guideline when providing
postoperative care for the following
clients?
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A continued decrease in blood pressure or an increase in heart rate could indicate
internal bleeding, and the physician should be notified. If an adult client has a urine
output of less than 30 mL per hour, the physician should be notified, unless this is
expected. If the client is febrile within 12 hours of surgery, the nurse should assist the
client with coughing and deep-breathing exercises. When large amounts of fresh
blood are present, the dressing should be reinforced with more bandages and the
physician notified.
35.
A diabetic client is undergoing surgery to amputate a gangrenous foot. This procedure would
be considered which of the
following categories of surgery based on purpose?
A)
Diagnostic
B)
Ablative
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C)
Palliative
D)
Reconstructive
Ans: B
Feedback:
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Ablative surgery is performed to remove a diseased body part. Diagnostic surgery is
performed to make or confirm a diagnosis. Palliative surgery involves relieving or
reducing intensity of an illness. Reconstructive surgery restores function to
traumatized or malfunctioning tissue.
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Chapter 32, Hygiene
Which client is most likely to require hospitalization related to problems associated with the
feet?
A)
A client with peripheral vascular disease
B)
A client with osteoporosis
C)
A client with asthma
D)
A client with diabetes insipidus
Ans: A
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1.
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Foot problems, particularly common in people with diabetes and peripheral vascular
disease, often require hospitalization.
A)
Partial care
B)
As-needed care
C)
Self-care
D)
Complete care
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2.
The nurse assists the client to the bathroom sink to perform morning care. The nurse
observes the client wash his face, arms, abdomen, and legs. The nurse washes the
client’s back and rectal area and applies soap to the back. The client brushes his teeth
and ambulates to a chair in his room with assistance. How will the nurse describe the
morning care on
the client’s chart?
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Ans: A
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Morning care is categorized as self-care, partial care, or complete care. Clients
identified as partial care most often receive morning care at the bedside, or seated
near the sink in the bathroom. They usually require assistance with body areas that
are difficult to reach. Clients identified as self-care are capable of managing their
personal hygiene independently once oriented to the bathroom. Clients identified as
complete care require nursing assistance with all aspects of personal hygiene. In
additional to scheduled care, the nurse will offer care as needed.
3.
Upon review of the client’s orders, the nurse notes that the client was recently started on an
anticoagulant. What is an
appropriate consideration when assisting the client with morning hygiene?
A)
Provide the client with an electric shaver.
B)
Provide the client with a firm bristled toothbrush.
C)
Do not allow the client to shower.
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D)
Avoid massaging the client’s back with lotion.
Ans: A
Feedback:
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Electric shavers are recommended when a client is receiving anticoagulant therapy.
In addition, the nurse should not provide a firm-bristled toothbrush because the client
is more prone to bleeding, and the firm bristles may lead to bleeding. The client
should be allowed to shower, unless there are other contraindications. A back
massage will provide an ideal time to perform a skin assessment for bruising or
breakdown.
A)
Apply moisture barriers to the skin of the perineal area.
B)
Provide excessive hydration to the skin of the perineal area.
C)
Wash the perineal area frequently with soap and water.
D)
Aggressively cleanse the perineal area with a washcloth or towel.
Ans: A
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4.
The nurse and nursing aid are providing perineal care for an incontinent client. What
information is important for the
nurse to consider when providing perineal care?
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Care to the perineal area for an incontinent client includes the use of moisture
barriers, skin cleansers, and moisturizers and the avoidance of soap or friction.
Measures should be followed to reduce overhydration because this will increase the
risk for perineal damage and skin breakdown.
A)
“Client normally bathes and washes her hair every other day; applies moisturizer to dry areas
on her elbows and
forearms.”
B)
“Client prioritizes personal hygiene in her daily routines and is proactive with skin care.”
C)
“Client bathes more often than necessary and consequently experiences dry skin.”
D)
“Client’s level of personal hygiene is acceptable and age-appropriate.”
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5.
The nurse has completed an assessment of a client’s typical hygiene practices. How should the
nurse best document the
findings of this assessment in the client’s chart?
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Ans: A
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When documenting the nursing history, it is best to be specific, clearly describing the
client’s typical hygiene practices and any complaints. Judgments regarding cause and
effect are likely premature in this context and may be inaccurate.
6.
An older adult resident of a long-term care facility has recurring problems with dry
skin. Which of the following strategies should the nursing staff utilize in order to help
meet the resident’s hygiene needs while preventing skin
dryness?
A)
Use a nonsoap cleaning agent.
B)
Use organic soap and shampoo.
C)
Bathe the client more often, but without using soap or shampoo.
D)
Provide the client with bed baths rather than tub baths.
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Ans: A
Feedback:
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Soap cleans the skin, but while it removes dirt from the surface, it affects the lipids
that are present on the skin, and the skin pH. This contributes to drier skin, damaging
the barrier function of the skin. The substitution of a nonsoap, emollient cleaning
agent is an easy way to prevent drying and damage to the skin. An organic soap is not
necessarily less drying to the skin. It would be inappropriate to forego the use of any
cleaning products whatsoever. Providing a bed bath rather than a tub bath will not
necessarily minimize dry skin.
A)
Use an antifungal powder on the client’s feet if necessary.
B)
Carefully remove any corns or calluses that are present.
C)
Soak the client’s feet for 15 to 20 minutes prior to cleansing.
D)
Avoid using soaps or commercial cleansers whenever possible.
Ans: A
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7.
A nurse is preparing to provide foot care to a client who has decreased mobility. Which of the
following techniques
should the nurse employ when providing this care?
Feedback:
Antifungal foot powders may be used when indicated, and it is appropriate to use
soap and/or cleansers when providing foot care. Corns and calluses should not be
removed, and the nurse should avoid soaking the client’s feet.
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Which of the following factors does not affect personal hygiene practices?
A)
Culture
B)
Income level
C)
Health state
D)
Gender
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Personal hygiene practices vary widely among individuals and are affected by
culture, socioeconomic status, spiritual practices, developmental level, health state,
and personal preferences.
A)
Socioeconomic class
B)
Culture
C)
Developmental level
D)
Health state
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9.
A homeless person uses the soap and towels in a public restroom to wash up. This is an
example of which type of factor
affecting personal hygiene practices?
Ans: A
Feedback:
A person’s socioeconomic class and financial resources often define the hygiene
options available to him or her. Access to assistive services, such as shelters, may be
limited for some clients. For example, homeless people, who often carry all their
belongings in a car or shopping cart, may welcome the warm running water and soap
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available in roadside or public restrooms.
Which clent would be at greatest risk for injury to the skin and mucous membranes?
A)
Infant 10 days old with no health problems
B)
adolescent 17 years of age with asthma
C)
Man 44 years of age with hemorrhoids
D)
Man 77 years of age with diabetes
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Ans: D
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Resistance to injury of the skin and mucous membranes varies among people. Factors
influencing resistance include the person’s age, the amount of underlying tissue, and
illness conditions. In this question, the older man with diabetes would be most at risk.
A)
“Perhaps you don’t recognize your bad body odor.”
B)
“You must eat a lot of greasy foods to have this acne.”
C)
“Tell me about what you do to take care of your skin.”
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11.
A nurse is conducting a health history for a client with a skin problem. What question or
statement would be most useful
in eliciting information about personal hygiene?
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D)
“Why do you only take a bath once a week?”
Ans: C
Feedback:
When skin problems are present, the nurse asks the client about usual personal
hygiene practices and documents the client’s responses. The questions should be
open-ended and nonthreatening.
Which client would be most at risk for alterations in oral health?
A)
Infant who is breast-fed
B)
Man with a nasogastric tube
C)
Woman who is pregnant
D)
Healthy young adult
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Ans: B
A variety of illnesses and habits may increase the risk for oral health problems,
including poor nutrition, treatment with chemotherapy, those who are NPO, and those
who have nasogastric tubes or oral airways in place.
13.
A student has been assigned to provide hygiene care to four clients. Which one would require
special consideration for
perineal care?
A)
Middle-aged man with a nasogastric tube
B)
Young adult man who has had a hernia repair
C)
Young woman who has had cosmetic surgery
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D)
Middle-age woman with a Foley catheter
Ans: D
Feedback:
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The dark, warm, moist perineal and vaginal areas favor bacterial growth. Variables
known to create a need for special care include an indwelling Foley catheter. The
client who cannot clean the perineal area needs the nurse’s assistance for personal
hygiene.
B)
Plaque
C)
Halitosis
D)
Caries
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Periodontitis
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While conducting an oral assessment, a nurse notices the client’s gums are red and swollen,
some teeth are loose, and
blood and pus can be expressed when the gums are palpated. What condition do these
symptoms indicate?
Feedback:
Periodontitis is a marked inflammation of the gums that also involves degeneration
of the dental periosteum (tissues) and bone. Symptoms include bleeding gums;
swollen, red, painful gum tissues; receding gumlines with the formation of pockets
between the teeth and gums; pus that appears when gums are pressed; and loose
teeth.
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A school nurse is assessing children in the third grade for pediculosis capitis. What
assessments should be made?
A)
The pubic area for growth of hair
B)
The head for nits on hair shafts
C)
The nails for evidence of cleanliness
D)
The body for evidence of abuse
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Infestation with lice is called pediculosis. Pediculosis capitis infests the hair and
scalp. Lice lay eggs, called nits, on the hair shafts. Nits are white or light gray and
look like dandruff, but cannot be brushed or shaken off the hair.
A)
Provide total physical hygiene, including perineal care.
B)
Provide total physical hygiene, excluding hair care.
C)
Provide supplies and orient to the bathroom.
D)
Provide supplies and assist with hard-to-reach areas.
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16.
A student has been assigned to provide morning care to a client. The plan of care includes the
information that the client
requires partial care. What will the student do?
Ans: D
Feedback:
Morning care is often identified as either self-care, partial care, or complete care.
Clients requiring partial morning care most often receive care at the bedside or seated
near the sink in the bathroom. They usually require assistance with body areas that
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are difficult to reach.
A)
None; they should be placed in saline
B)
To increase comfort when replaced in the mouth
C)
To prevent drying and warping of plastic
D)
To ensure the dentures are not thrown away
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17.
Before a long-term care resident goes to sleep at night, his dentures are placed in a denture cup
with clean water. What
rationale supports placing dentures in water?
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Ans: C
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If a client removes dentures while sleeping, they should be stored in water in a
disposable denture cup to prevent drying and warping of plastic materials.
A nurse is providing oral care to a client with dentures. What action would the nurse do first?
A)
Assess the mouth and gums.
B)
Don gloves.
C)
Wash the client’s face.
D)
Apply lubricant.
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Ans: B
Feedback:
When providing oral care and denture care, the nurse would be exposed to body
fluids. The nurse should always don gloves if exposure to body fluids will occur.
A)
“That’s not good. Use a Q-tip or your finger instead.”
B)
“You really like to keep your child clean. Good for you!”
C)
“That is dangerous; you might puncture the eardrum.”
D)
“Show me exactly how you use the hairpin.”
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19.
The mother of a child 2 years of age tells the nurse she always cleans the child’s ears with a
hairpin. What would the
nurse tell the mother?
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Ans: C
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Little intervention is needed for routine hygiene of the ear. Using bobby pins,
hairpins, paper clips, or fingernails to remove wax from the ear is extremely
dangerous because these may injure or puncture the eardrum.
20.
A nurse is providing perineal care to a female client. In which direction would the nurse move
the washcloth?
A)
From the pubic area toward the anal area
B)
From the anal area to the pubic area
C)
From side to side within the labia
D)
The direction does not make any difference
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Ans: A
Feedback:
Always proceed from the least contaminated area to the most contaminated area. For
a female client, spread the labia and move the washcloth from the pubic area toward
the anal area to prevent carrying organisms from the anal area back over to the
genital area.
A)
Yes, this helps prevent vaginal odor.
B)
Yes, this decreases vaginal secretions.
C)
No, douching removes normal bacteria.
D)
No, douching may increase secretions.
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21.
A female client in a reproductive health clinic tells the nurse practitioner that she douches
every day. Should the nurse
tell the client to continue this practice?
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Ans: C
Feedback:
In normal healthy women, daily douching is believed to be unnecessary because it
removes normal bacterial flora from the vagina. Douching has been linked to
bacterial vaginosis, pelvic inflammatory disease, higher rates of HIV transmission,
tubal pregnancies, chlamydial infection, and cervical cancer.
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22.
An older adult client with Parkinson’s disease is unable to take care of himself. The client
frequently soils his bed and is
unable to clean himself independently. How should the nurse in this case ensure the client’s
perineal care?
Cleanse to remove secretions from less-soiled to more-soiled areas.
B)
Cleanse using a cotton cloth and warm water.
C)
Use tissue rolls to clean the client’s perineal area.
D)
Provide the client with a bed pan or a jar to collect the urine.
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To ensure proper perineal care, the nurse should cleanse to remove secretions and
excretions from less-soiled to more- soiled areas. The nurse must also prevent direct
contact with and any secretions or excretions by wearing clean gloves. The nurse
should not use cotton cloth or tissues to clean the perineal area because that might
lead to skin impairment. Older adult clients have sensitive skin, which may be easily
impaired when cleaning. Because the client cannot do anything independently,
providing him with a bed pan or a jar will not help.
23.
A nurse is assessing a client during a health care camp. The nurse observes that the client has
poor hygiene and an itchy,
infected scalp. Which of the following should the nurse ask the client to do?
A)
Wash hair daily
B)
Use dry shampoo
C)
Use oil-based shampoo
D)
Use anti-lice shampoo
Ans: A
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Feedback:
The client with a scalp infection should be advised to shampoo her hair daily with a
mild shampoo. For occasional use, the nurse will use dry shampoos, which are
applied to the hair as a powder. Other options include aerosol spray or foam. Antilice shampoos or oil-based shampoos are not used for fear of aggravating the
infection.
Facilitates oil distribution
B)
Cleans hair and scalp
C)
Removes excess oil
D)
Cleans the hair of dirt
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24.
A nurse is brushing the hair of a client admitted to the health care facility following a fracture
in the hand. The nurse
implements this action based on the understanding that brushing the hair achieves which of the
following?
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Ans: A
Brushing the hair facilitates oil distribution along the hair shaft more effectively than
combing, as well as massages the scalp and stimulates circulation. Shampooing
cleans the hair and scalp, helps get rid of excess oil, and cleans the hair of dirt. It
provides a relaxing, soothing experience for the client.
25.
On the first postoperative day, the client is assisted to the bathroom. It is important for the
nurse to do what?
A)
Allow the client privacy
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B)
Assess the client’s safety
C)
Assess the client’s pain
D)
Allow sufficient time
Ans: B
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Feedback:
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Toileting often is associated with falls; the nurse must ensure the client’s safety.
A client age 78 years with diabetes needs to have his toenails trimmed. It is important for the
nurse to do what?
A)
Remove ingrown toenails
B)
Cut the nail straight across
C)
Protect the foot from blisters
D)
Soak the foot in witch hazel
Ans: B
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26.
Feedback:
The feet of older adults require special attention, because foot problems may relate to
reduced peripheral blood flow. Poor circulation makes the feet more vulnerable to
infection and skin breakdown, particularly after trauma. By cutting the nail straight
across, the nurse can protect the toes from trauma.
27.
What type of bath is preferred to decrease the inflammation after rectal surgery?
A)
Bed bath
B)
Tub bath
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C)
Whirlpool bath
D)
Sitz bath
Ans: D
Feedback:
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A sitz bath can be helpful in soaking a client’s pelvic area in warm water to decrease
inflammation after childbirth or rectal surgery, or to decrease inflammation of
hemorrhoids.
Which of the following clients ia at an increased risk for oral problems? Select all that apply.
A)
Comatose client
B)
Confused client
C)
Depressed client
D)
Client undergoing chemotherapy
E)
Hypertensive client
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28.
Ans: A, B, C, D
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Clients at increased risk for oral problems include those who are seriously ill,
comatose, dehydrated, confused, depressed, or paralyzed. Clients who are mouth
breathers, those who can have no oral intake of nutrition or fluids, those with
nasogastric tubes or oral airways in place, and those who have had oral surgery are
also at increased risk. Variables known to cause oral problems include deficient selfcare abilities, poor nutrition or excessive intake of refined sugars, family history of
periodontal disease, or ingestion of chemotherapeutic agents that produce oral
lesions.
A)
Use an emery board to file toe nail edges
B)
Cut the toenails short
C)
Cut the nail in one piece
D)
Avoid cutting into calluses
E)
Cut the nails straight across
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29.
What care should the nurse take when providing foot care for a client with peripheral vascular
disease? Select all that
apply.
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Ans: A, D, E
Feedback:
The nurse caring for the client with peripheral vascular disease should use an emery
board to file nail edges. These clients may have thick distorted nails that may be
difficult to cut, but can be safely filed. The nurse should avoid cutting the nails too
short or cutting into calluses to prevent trauma. The nurse should cut the nails
straight across if possible, and cut in a few small pieces rather than one piece to
prevent injury or skin breakdown.
30.
The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place.
Which of the following
actions is correct?
A)
Remove the antiembolism stockings during the bath.
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B)
Leave the antiembolism stockings in place, but be sure to remove all wrinkles.
C)
Fold the antiembolism stockings half-way down to allow assessment of the popliteal pulse.
D)
Leave the antiembolism stockings in place and spot-clean any soiled areas on the stockings.
Ans: A
Feedback:
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Antiembolism stockings should be removed periodically to allow for assessment.
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Retract the foreskin while washing the penis; then, immediately pull the foreskin back into
place.
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31.
The nurse is preparing to perform perineal care on an uncircumcised adult male client who
was incontinent of stool. The
client’s entire perineal area is heavily soiled. Which of the following techniques for cleaning
the penis is correct?
C)
Avoid retraction of the foreskin because injury and scarring could occur.
D)
Soak the end of the penis in warm water before cleaning the shaft of the penis.
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B)
Retract the foreskin while washing the penis, allow 10 to 15 minutes for the glans penis to dry;
then, replace the foreskin
in its original position.
Ans: A
Feedback:
Failing to pull the foreskin back into place may cause tissue damage to the penis.
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32.
The nurse has completed bed bath on a client who is obese. The client asks you to sprinkle
baby powder in the perineal
area. Which of the following actions is correct?
Inform the client that baby powder is not used because it may become a medium for bacterial
growth.
B)
Carefully apply baby powder to skin folds only.
C)
Pour a small amount of powder into the hand and gently pat the perineal area while avoiding
aerosolization of the
powder.
D)
Apply a generous amount of baby powder to all areas where skin touches skin.
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A)
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Ans: A
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Feedback:
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Failing to pull the foreskin back into place may cause tissue damage to the penis.
Which of the following is a correct guideline to follow when providing a bed bath for a client?
A)
When cleaning the eye, move the washcloth from the outer to the inner aspect of the eye.
B)
Fold the washcloth like a mitt on your hand so that there are no loose ends.
C)
Clean the perineal area before cleaning the gluteal area.
D)
Change the bath water after washing each body part.
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33.
Ans: B
Feedback:
Fold the washcloth like a mitt on your hand so that there are no loose ends. Moving
from the inner to the outer aspect of the eye prevents carrying debris toward the
nasolacrimal duct. The gluteal area should be cleaned first and the bathwater and
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towels should be changed before cleaning the perineal area. It is not necessary to
change the bath water after washing every body part.
A)
Cover the client with a blanket.
B)
Fill a basin with cool water.
C)
Apply cream to area to be shaved in a layer about 1/2-inch thick.
D)
Shave against the direction of hair growth in upward, short strokes
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34.
A nurse is assisting a client to shave his beard. Which of the following statements accurately
describes a recommended
step in this process?
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Steps in the procedure include: Cover patient’s chest with a towel or waterproof pad.
Fill bath basin with warm (43ºC to 46ºC [110ºF to 115ºF]) water. Put on gloves.
Moisten the area to be shaved with a washcloth. Dispense shaving cream into palm of
hand. Apply cream to area to be shaved in a layer about 1/2-inch thick. With one
hand, pull the skin taut at the area to be shaved. Using a smooth stroke, begin
shaving. If shaving the face, shave with the direction of hair growth in downward,
short strokes. If shaving a leg, shave against the hair in upward, short strokes. If
shaving an
underarm, pull skin taut and use short, upward strokes.
35.
A client is admitted to the health care facility with a diagnosis of pediculosis capitis. Which of
the following would the
nurse expect to find in the client?
A)
Diffuse scaling of the epidermis
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B)
Itching and flaking of whitish scales
C)
Premature loss of hair
D)
Inflammation related to bites along the hairline
Ans: D
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The nurse would find inflamed bites along the hairline in the client with pediculosis
infestation. Diffuse scaling of the epidermis with itching and flaking of whitish scales
is seen in clients who have dandruff. Hair loss is not a manifestation of pediculosis
capitis.
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Chapter 33, Skin Integrity and Wound Care
C)
Inflammatory phase
D)
Maturation phase
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Hemostasis
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Proliferation phase
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Upon assessment of a client’s wound, the nurse notes the formation of granulation tissue. The
tissue easily bleeds when
the nurse performs wound care. What is the phase of wound healing characterized by the
nurse’s assessment?
Ans: A
Feedback:
The proliferation phase is characterized by the formation of granulation tissue (highly
vascular, red tissue that bleeds easily). During the proliferation phase, new tissue is
built to fill the wound space. Hemostasis involves the constriction of blood vessels
and the beginning of blood clotting immediately after the initial injury. The
inflammatory phase lasts about four to six days, and white blood cells and
macrophages move to the wound. The maturation phase is the final phase of wound
healing and involves remodeling of collagen that was haphazardly deposited in the
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wound; in addition, a scar forms.
A)
Covering the wound area with sterile towels moistened with sterile 0.9% saline
B)
Closing the wound area with Steri-Strips
C)
Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze
D)
Holding the wound together until the physician arrives
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2.
Upon responding to the client’s call bell, the nurse discovers the client’s wound has dehisced.
Initial nursing
management includes calling the physician and doing which of the following?
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If dehiscence occurs, cover the wound area with sterile towels moistened with sterile
0.9% saline. The client should also be placed in the low Fowler’s position, and the
exposed abdominal contents should be covered as previously discussed. Notify the
physician immediately because this is a medical emergency. Do not leave the client
alone.
A)
Stage I pressure ulcer
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3.
The wound care clinical nurse specialist has been consulted to evaluate a wound on
the leg of a client with diabetes. The wound care nurse determines that damage has
occurred to the subcutaneous tissues; how would she document this
wound?
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B)
Stage II pressure ulcer
C)
Stage III pressure ulcer
D)
Stage IV pressure ulcer
Ans: C
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Damage to the subcutaneous tissue indicates a stage III ulcer. Extensive destruction
associated with full-thickness skin loss is categorized as a stage IV pressure ulcer. A
stage I ulcer is a defined area of persistent redness in lightly pigmented skin and a
persistent red, blue, or purple hue in darker pigmented skin. A stage II pressure ulcer
is superficial and may present as a blister or abrasion.
A)
Perform hand hygiene.
B)
Insert a swab into the wound at 90 degrees.
C)
Measure the width of the wound with a disposable ruler.
D)
Assess the condition of the visible wound bed.
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4.
When measuring the size, depth, and wound tunneling of a client’s stage IV pressure ulcer,
what action should the nurse
perform first?
Ans: A
Feedback:
Hand hygiene should precede any wound assessment or wound treatment.
5.
The nurse would recognize which of these devices as an open drainage system?
A)
Penrose drain
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B)
Jackson-Pratt drain
C)
Hemovac
D)
Negative pressure dressing
Ans: A
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A)
Abrasion
B)
Ecchymosis
C)
Incision
D)
Puncture wound
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Which is an example of a closed wound?
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A Penrose drain is an open system that lacks a collection device. Jackson-Pratt drains,
Hemovacs, and negative pressure dressings all utilize a suction device or collection
reservoir and are considered to be closed systems.
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A closed wound results from a blow, force, or strain caused by trauma (such as a fall,
an assault, or a motor vehicle crash). The skin surface is not broken, but soft tissue is
damaged, and internal injury and hemorrhage may occur. Examples include
ecchymosis and hematomas. An open wound occurs from intentional or
unintentional trauma. The skin surface is broken, providing a portal of entry for
microorganisms. Bleeding, tissue damage, and increased risk for infection and
delayed healing may accompany open wounds. Examples include incisions and
abrasions.
What are the two major processes involved in the inflammatory phase of wound healing?
A)
Bleeding is stimulated, epithelial cells are deposited
B)
Granulation tissue is formed, collagen is deposited
C)
Collagen is remodeled, avascular scar forms
D)
Blood clotting is initiated, WBCs move into the wound
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Ans: D
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The inflammatory phase of wound healing begins at the time of injury and prepares
the wound for healing. The two major physiologic activities are blood clotting
(hemostasis) and the vascular and cellular phase of inflammation.
8.
A nurse is caring for a client who is two days postoperative after abdominal surgery. What
nursing intervention would
be important to promote wound healing at this time?
A)
Administer pain medications on a p.r.n. and regular basis.
B)
Assist in moving to prevent strain on the suture line.
C)
Tell the client that a mild fever is a normal response.
D)
If a scar forms over a joint, it may limit movement.
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Ans: B
Feedback:
The proliferative phase of wound healing begins within two to three days of the
injury. Collagen synthesis and accumulation continue, peaking in five to seven days.
During this time, adequate nutrition, oxygenation, and prevention of strain on the
suture line are important client care considerations.
A)
An infant
B)
A young adult
C)
A middle adult
D)
An older adult
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9.
A home health nurse has a caseload of several postoperative clients. Which one would be most
likely to require a longer
period of care?
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Ans: D
An older adult heals more slowly than do children and adults as a result of
physiologic changes of aging, resulting in diminished fibroblastic activity and
circulation. Older adults are also more likely to have one or more chronic illnesses,
with pathologic changes that impede the healing process.
10.
A nurse is educating a postoperative client on essential nutrition for healing. What statement
by the client would indicate
a need for more information?
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A)
“I will drink a lot of orange juice and drink milk, too.”
B)
“I will take the zinc supplement the doctor recommended.”
C)
“I will restrict my diet to fats and carbohydrates.”
D)
“I will drink 8 to 10 glasses of water every day.”
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Ans: C
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Wound healing requires adequate proteins, carbohydrates, fats, vitamins, and
minerals. Calories and proteins are necessary to rebuild cells and tissues. Vitamins C
and D, zinc, and adequate fluids are also necessary for wound healing.
A)
Self-care Deficit
B)
Risk for Imbalanced Nutrition
C)
Anxiety
D)
Risk for Infection
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11.
What nursing diagnosis would be a priority for a client who has a large wound from colon
surgery, is obese, and is
taking corticosteroid medications?
Ans: D
Feedback:
Clients who are taking corticosteroid medications are at high risk for delayed healing
and wound complications such as infections, because corticosteroids decrease the
inflammatory process that may in turn delay healing.
A nurse working in long-term care is assessing residents at risk for the development of a
decubitus ulcer. Which one
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12.
would be most at risk?
A)
A client 83 years of age who is mobile
B)
A client 92 years of age who uses a walker
C)
A client 75 years of age who uses a cane
D)
A client 86 years of age who is bedfast
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Most pressure ulcers occur in older adults as a result of a combination of factors,
including aging skin, chronic illness, immobility, malnutrition, fecal and urinary
incontinence, and altered level of consciousness. The bedfast resident would be most
at risk in this situation.
What intervention should be included on a plan of care to prevent pressure ulcer development
in health care settings?
A)
Change position at least once each shift.
B)
Implement a turning schedule every two hours.
C)
Use ring cushions for heels and elbows.
D)
Do not turn; use pressure-relieving support surface.
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13.
Ans: B
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To protect clients at risk from the adverse effects of pressure, implement turning
using an every-2-hour schedule in the health care setting. More frequent position
changes may be necessary. Never use ring cushions or “donuts.”
A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer
would be expected?
A)
Full-thickness skin loss
B)
Skin pallor
C)
Blister formation
D)
Eschar formation
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A stage IV pressure ulcer is characterized by the extensive destruction associated with fullthickness skin loss.
During a dressing change, the nurse assesses protrusion of intestines through an opened
wound. What would the nurse
do after covering the wound with towels moistened with sterile 0.9% sodium chloride
solution?
A)
Document the assessments and intervention.
B)
Reinforce the dressing with additional layers.
C)
Administer pain medications intramuscularly.
D)
Notify the physician and prepare for surgery.
Ans: D
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Feedback:
Protrusion of the intestines through an opened wound indicates evisceration. After
covering the wound with towels soaked in sterile normal saline, the nurse should
immediately notify the physician. Immediate surgical repair is required.
A)
Clear, watery blood
B)
Large numbers of red blood cells
C)
Mixture of serum and red blood cells
D)
White blood cells, debris, bacteria
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16.
A nurse assessing a client’s wound documents the finding of purulent drainage. What is the
composition of this type of
drainage?
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Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and
both dead and live bacteria. Purulent drainage is thick, often has a musty or foul
odor, and varies in color (such as dark yellow or green), depending on the causative
organism. Serous drainage is composed primarily of the clear, serous portion of the
blood and from serous membranes. Serous drainage is clear and watery. Sanguineous
drainage consists of large numbers of red blood cells and looks like blood. Bright-red
sanguineous drainage is indicative of fresh bleeding, whereas darker drainage
indicates older bleeding. Serosanguineous drainage is a mixture of serum and red
blood cells. It is light pink to
blood tinged.
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A)
Question the physician about the accuracy of this agent.
B)
Refuse to use 0.9% normal saline on a wound.
C)
Document the rationale for not changing the dressing.
D)
Continue with the dressing change as planned.
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17.
The plan of care for a postoperative client specifies that sterile 0.9% sodium chloride solution
be used to clean the
wound. What should the nurse do after reading this information?
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Although various antiseptic cleaning agents could be used to clean a wound, sterile
0.9% normal saline is usually the agent of choice. Other agents may be caustic to skin
and tissues.
A)
“Oh, for gosh sakes…it doesn’t look that bad!”
B)
“I understand, but you are going to have to look someday.”
C)
“I respect your wish not to look at it right now.”
D)
“You won’t be able to go home until you look at it.”
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18.
A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at
the wound during
dressing changes. Which response by the nurse is appropriate?
Ans: C
Feedback:
The sight of the wound may disturb a client. If the wound involves a change in
normal body functions or appearance, the pclient may not want to look at the wound.
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With patience and emotional support, clients learn to cope with and adapt to their
wounds in time.
A)
“I understand the rebound effect of heat.”
B)
“I will put the heat packs only on the sore on my leg.”
C)
“I will only leave the heat packs on for 20 minutes.”
D)
“I will leave the heat packs on for an hour.”
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19.
A nurse is teaching a client on home care about how to apply hot packs to an infected leg
ulcer. What statement by the
client indicates the need for further education?
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Initially, temperature receptors in the skin are strongly stimulated. This response
decreases rapidly for the first few seconds after being stimulated and more slowly
for the next 30 minutes as the receptors adapt to the temperature. Be sure to tell
clients that increasing the temperature or lengthening the time of application can
seriously damage tissues.
20.
Of the many topics that may be taught to clients or caregivers about home wound care, which
one is the most significant
in preventing wound infections?
A)
Taking medications as prescribed
B)
Proper intake of food and fluids
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C)
Thorough hand hygiene
D)
Adequate sleep and rest
Ans: C
Feedback:
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The single most important information on which to educate clients and caregivers
about home wound care is the importance of thorough hand hygiene to prevent
wound infections.
Which of the following is a recommended guideline nurses follow when using an electric
heating pad on a client?
A)
Secure the heating pad to the client’s clothing with safety pins.
B)
Place a heavy towel or blanket over the heating pad to maximize heat effects.
C)
Use a heating pad with a selector switch that can be turned up by the client if needed.
D)
Place a heating pad anteriorly or laterally to, not under, the body part.
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21.
Feedback:
Guidelines include: Place a heating pad anteriorly or laterally to, not under, the body
part. If the heating pad is between the client and the mattress, heat dissipation may
be inadequate, leading to burning of the client or the bed linens. Avoid using pins to
secure a heating pad because there is a danger of electric shock if a pin touches a
wire. Do not cover the heating pad with anything that might be heavy; heat may
accumulate and burn the client when it cannot dissipate normally from the pad. Use a
heating pad with a selector switch that cannot be turned up beyond a safe
temperature.
22.
A nurse caring for a female client notes a number of laceration wounds around the cervix of
the uterus due to childbirth.
How could the nurse describe the laceration wound in the client’s medical record?
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A)
A clean separation of skin and tissue with a smooth, even edge
B)
A separation of skin and tissue in which the edges are torn and irregular
C)
A wound in which the surface layers of skin are scraped away
D)
A shallow crater in which skin or mucous membrane is missing
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Ans: B
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A laceration wound can be described as a separation of skin and tissue in which the
edges are torn and irregular. An incision wound is described as a clean separation of
skin and tissue with a smooth, even edge. An abrasion is a wound in which the
surface layers of skin are scraped away. Ulceration is a shallow crater in which skin
or mucous membrane is missing.
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23.
A nurse caring for a post-operative client observes the drainage in the client’s closed wound
drainage system. The
drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of
the following?
Serous
B)
Sanguineous
C)
Serosanguineous
D)
Purulent
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Ans: C
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Feedback:
The nurse should document the drainage as serosanguineous, which is pale pinkyellow, thin, and contains plasma and red cells. Serous drainage is pale yellow and
watery, like the fluid from a blister. Sanguineous drainage is bloody, as from an
acute laceration. Purulent drainage contains white cells and microorganisms and
occurs when infection is present. It is thick and opaque and can vary from pale
yellow to green or tan, depending on the offending organism.
A)
Beta-hemolytic streptococcus
B)
Age
C)
Venous insufficiency
D)
Hemangioma
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24.
An older adult client has edema of the right lower extremity with redness and clear drainage.
This is most likely related
to what?
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Ans: C
Leg and foot ulcers occur from various causes, but the most common are ulcers
secondary to venous insufficiency, arterial insufficiency, and neuropathy.
25.
Which of the following clients would be considered at risk for skin alterations? Select all that
apply.
A)
A teenager with multiple body piercings
B)
A homosexual in a monogamous relationship
C)
A client receiving radiation therapy
D)
A client undergoing cardiac monitoring
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E)
A client with diabetes
Ans: A, C, E
Feedback:
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Body piercings, radiation therapy, and diabetes place clients at risk for skin
alterations. Having a homosexual relationship with multiple partners would also
place a client at risk for HIV and skin alterations. Cardiac monitoring and respiratory
disorders are not risk factors.
A)
Constricts peripheral blood vessels
B)
Reduces muscle spasms
C)
Increases blood flow to tissues
D)
Increases the local release of pain-producing substances
E)
Reduces the formation of edema and inflammation
Ans: A, B, E
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26.
A nurse is applying cold therapy to a client with a contusion of the arm. Which of the
following is an effect of cold
therapy? Select all that apply.
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The local application of cold constricts peripheral blood vessels, reduces muscle
spasms, and promotes comfort. Cold reduces blood flow to tissues and decreases the
local release of pain-producing substances such as histamine, serotonin, and
bradykinin. This action in turn reduces the formation of edema and inflammation.
Decreased metabolic needs and capillary permeability, combined with increased
coagulation of blood at the wound site, facilitate the control of bleeding and reduce
edema formation. Cold also reduces muscle spasms, alters tissue sensitivity
(producing numbness), and promotes comfort by slowing the transmission of pain
stimuli.
Which of the following are functions of the skin? Select all that apply.
A)
Protection
B)
Temperature regulation
C)
Sensation
D)
Vitamin C production
E)
Immunological
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27.
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Ans: A, B, C, E
The skin provides multiple functions: protection, temperature regulation, psychosocial,
sensation, vitamin D production, immunological, absorption, and elimination.
28.
While performing a bed bath, the nurse notes an area of tissue injury on the client’s
sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed
and partial thickness loss of dermis. Which of the following is the
correct name of this wound?
A)
Stage II pressure ulcer
B)
Stage I pressure ulcer
C)
Stage III pressure ulcer
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D)
Stage IV pressure ulcer
Ans: A
Feedback:
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Stage I is defined as intact skin with a localized area of nonblanchable redness,
usually over a bony prominence. Stage II is defined as partial thickness loss of dermis
presenting as a shallow open ulcer with a red-pink wound bed. Stage III is defined as
full-thickness loss without exposed bone, tendon, or muscle. Stage IV is defined as
full-thickness tissue loss with exposed bone, tendon, and muscle.
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Upon inspection the nurse would notice a purple or maroon localized area of discolored, intact
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29.
A nurse is treating the pressure ulcer of an African American client. How would the nurse
assess for deep tissue injury in
this client?
C)
Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful,
firm, boggy, warmer or
cooler as compared with adjacent tissue.
D)
Upon inspection the nurse notes partial thickness loss of dermis presenting as a shallow open
ulcer with a red-pink
wound bed, without slough.
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B)
Upon inspection, the nurse would see a blood-filled blister due to damage of underlying soft
tissue from pressure and/or
shear.
Ans: C
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Feedback:
Deep tissue injury may be difficult to detect in individuals with dark skin tones. The
area may be preceded by tissue that is painful, firm, boggy, warmer or cooler as
compared with adjacent tissue. Evolution may include a thin blister over a dark
wound bed. The wound may further evolve and become covered by a thin eschar.
Evolution may be rapid, exposing additional layers of tissue even with optimal
treatment.
Stage I
B)
Stage II
C)
Stage III
D)
Stage IV
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30.
A nurse inspecting a client’s pressure ulcer documents the following: full-thickness tissue loss;
visible subcutaneous fat;
bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of
the following stages?
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Ans: C
In stage III there is full-thickness tissue loss; subcutaneous fat may be visible, but
bone, tendon, or muscle are not exposed. In stage I there is intact skin with
nonblanchable redness of a localized area, usually over a bony prominence. In stage
II there is partial thickness loss of dermis presenting as a shallow open ulcer with a
red-pink wound bed, without slough. In stage IV, there is full-thickness tissue loss
with exposed bone, tendon, or muscle.
31.
Which of the following is an accurate step when applying a saline-moistened dressing on a
client’s wound?
A)
Do not use irrigation to clean the wound before changing the dressing.
B)
Hold the fine-mesh gauze over the basin and pour the ordered solution over the mesh to
saturate it.
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C)
Exert light pressure to pack the wound tightly with moistened dressing.
D)
Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the
gauze.
Ans: D
Feedback:
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Answer D is the correct step in the procedure. The wound should be cleaned, if
needed, using sterile forceps. Irrigation may be used as ordered or required. The
wound should be cleaned from the top to the bottom, and from the center to the
outside. The fine-mesh gauze should be placed into the basin and the ordered
solution poured over the mesh to saturate it. The dressing should be gently and
loosely packed inside the wound.
A)
Saline-moistened dressing
B)
Dressing secured with Montgomery straps
C)
Hydrocolloid dressing
D)
Foam dressing
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32.
A physician orders a dressing to cover a wound that is shallow with minimal drainage. What
would be the best type of
dressing for this wound?
Ans: C
Feedback:
Hydrocolloid dressings are used for wounds that are shallow to moderate depth with
minimal drainage. Saline-moistened dressing is often used with chronic wounds and
pressure wounds. Montgomery straps are recommended to secure
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dressings on wounds that require frequent dressing changes, such as wounds with
increased drainage. Foam dressings are recommended for chronic wounds.
Which of the following is an indication for the use of negative pressure wound therapy?
A)
Bone infections
B)
Malignant wounds
C)
Wounds with fistulas to body cavities
D)
Pressure ulcers
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33.
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Negative pressure wound therapy (NPWT) is used to treat a variety of acute or
chronic wounds, wounds with heavy drainage, wounds failing to heal, or wounds
healing slowly. Examples of such wounds include pressure ulcers; arterial, venous,
and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and
burns. NPWT is not considered for use in the presence of active bleeding; wounds
with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence
of dry/necrotic tissue; or with fistulas of unknown origin (Hess, 2008; Preston, 2008;
Thompson, 2008).
34.
A student has been assigned to provide morning care to a client. The plan of care includes the
information that the client
requires partial care. What will the student do?
A)
Provide total physical hygiene, including perineal care.
B)
Provide total physical hygiene, excluding hair care.
C)
Provide supplies and orient to the bathroom.
D)
Provide supplies and assist with hard-to-reach areas.
Ans: D
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Feedback:
Morning care is often identified as either self-care, partial care, or complete care.
Clients requiring partial morning care most often receive care at the bedside or seated
near the sink in the bathroom. They usually require assistance with body areas that
are difficult to reach.
Chapter 34, Activity
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1.
A staff development nurse is discussing techniques to prevent back injury with a group of
nursing assistants. The nurse
informs the group that back stress and injury can be prevented by doing which of the
following?
Spreading feet shoulder-width apart to broaden the base of support
B)
Using the strength of the back muscles during strenuous activities
C)
Holding the object that you are lifting or moving away from the body
D)
Pulling equipment, rather than pushing it, when possible
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A)
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Ans: A
Techniques that prevent back stress and injury include spreading the feet shoulderwidth apart to broaden the base of support; pushing equipment, rather than pulling,
whenever possible; holding the object you are lifting or moving close to
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the body; and using the longest and strongest muscles of the arms and legs to provide power, since the muscles of the
back are less strong and more easily injured.
A)
Paralysis of the legs
B)
Weakness affecting one-half of the body
C)
Paralysis affecting one-half of the body
D)
Paralysis of the legs and arms
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2.
While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care
for this client based upon
the understanding that the client has which of the following?
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Paraplegia is paralysis of the legs, and quadriplegia is paralysis of the arms and legs.
Hemiparesis refers to weakness of one half of the body, and hemiplegia is paralysis of
one half of the body.
A)
45 to 60 degrees
B)
15 to 20 degrees
C)
30 degrees
D)
90 degrees
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3.
The physician’s admitting orders indicate that the client is to be placed in a Fowler’s position.
Upon positioning this
client, how much will the nurse elevate the head of the bed?
Ans: A
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the body; and using the longest and strongest muscles of the arms and legs to provide power, since the muscles of the
In the Fowler’s position, the head of the bed is elevated 45 to 60 degrees. LowFowler’s or semi-Fowler’s is positioning of the head of the bed to only 30 degrees. In
the high-Fowler’s position, the head of the bed is elevated 90 degrees.
D)
Semi-Fowler’s
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Protective supine
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4.
A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following
a recent stroke, but his
care team wishes to now begin introducing minced and pureed food. How should the nurse
best position the client?
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Ans: A
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Fowler’s position optimizes cardiac function and respiratory function in addition to
being the best position for eating. The client’s risk of aspiration would be extreme in
a supine position. Low-Fowler’s and semi-Fowler’s are synonymous, and this
position does not aid swallowing as much as a high-Fowler’s position.
5.
An obstetrical nurse is preparing to help a client up from her bed and to the bathroom three
hours after the woman
delivered her baby. Which of the following actions should the nurse perform first?
A)
Explain to the client how the nurse will assist her.
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B)
Position a walker in front of the client to provide stability.
C)
Enlist the assistance of another nurse or the physiotherapist.
D)
Have the client stand for 30 seconds prior to walking.
Ans: A
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Any effort to assist a client with mobilization should be preceded by thoroughly
explaining the procedure; this optimizes the client’s participation and lessens the
potential for falls and injuries. The client is unlikely to require a walker or the
assistance of multiple care providers, but even if she did, an explanation should still
be provided first. It is not necessary to have the client stand for an extended period
before ambulating.
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6.
A client 86 years of age with a diagnosis of late-stage Alzheimer’s disease requires full
assistance with transfers to and
from his bed. Which of the following nursing actions is most likely to promote safe handling
of this client?
Provide to the client brief, clear instructions that are phrased positively.
B)
Post written instructions at the client’s bedside to supplement spoken instructions.
C)
Ask for the client’s input on the timing and technique for transfers.
D)
Ask for the client’s feedback frequently during transfers.
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A)
Ans: A
Feedback:
When handling clients who have dementia, clear, short instructions are most
effective. These instructions should be phrased positively (“stand up” rather than
“don’t sit down”). For a client with an advanced state of dementia, asking for
feedback during transfers, and input on planning transfers is likely to be ineffective
and may be frustrating for both the client and the nurse.
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7.
A nurse is providing care for a client who has been newly admitted to the long-term care
facility. What is the primary
criterion for the nurse’s decision whether to use a mechanized assistive device for transferring
the client?
The client’s ability to assist
B)
The client’s body weight
C)
The client’s cognitive status
D)
The client’s age
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A)
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Ans: A
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The nurse assesses several parameters when choosing whether to use a mechanized
assistive device for a client transfer. The most important consideration, however, is
the client’s ability to safely assist with his or her transfer.
What function of the skeletal system is essential to proper function of all other cells and
tissues?
A)
Supporting soft tissues of the body
B)
Protecting delicate body structures
C)
Providing storage area for fats
D)
Producing blood cells
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Ans: D
Feedback:
The production of blood cells (hematopoiesis) is the function of the skeletal system
that is essential to all other cells and tissues of the body working properly.
A nurse is assessing the activity level of an infant age 5 months. What normal findings would
be assessed?
A)
Ability to sit and head control
B)
Ability to pick up small objects
C)
Progress toward running and jumping
D)
Progress toward unassisted walking
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9.
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At 5 months of age, the infant usually has achieved head control and is able to sit
alone. Individual variations in activity patterns and neuromuscular development
should be expected.
10.
Which postural deformity might be assessed in a teenager?
A)
Kyphosis
B)
Rickets
C)
Osteoporosis
D)
Scoliosis
Ans: D
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Feedback:
Scoliosis, a lateral curvature of the spine, would most likely be assessed in a
teenager. Kyphosis and osteoporosis are seen in older adults. Rickets is seen in
children.
A)
Minimize stress on the wife’s joints
B)
Povide exercise for the husband
C)
Increase socialization with neighbors
D)
Maintain self-esteem of the wife
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11.
A nurse is teaching an older woman how to move and lift her disabled husband. The woman
has osteoarthritis of the hips
and knees. What is the goal of the nurse’s education plan?
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Older adults often have osteoarthritis, a noninflammatory progressive disorder of
the moveable joints, particularly weight-bearing joints. Teaching clients to
minimize stress on the joints to prevent possible injury and reduce pain is
important.
12.
Why is it important for the nurse to teach and role model proper body mechanics?
A)
To ensure knowledgeable client care
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B)
To promote health and prevent illness
C)
To prevent unnecessary insurance claims
D)
To demonstrate knowledge and skills
Ans: B
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The correct use of body mechanics is a part of health promotion and illness
prevention. The nurse has a major responsibility to teach good body mechanics, both
directly and indirectly, by example.
A nurse is placing a client in Fowler’s position. What should she teach the family about this
position?
A)
“Use at least two big pillows to support the head.”
B)
“Cross the arms over the client’s abdomen.”
C)
“Do not raise the knees with the knee gatch.”
D)
“Keep the hands lower than the rest of the body.”
Ans: C
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13.
Feedback:
When positioning the client in Fowler’s position, allow the head to rest against the
mattress or use only a small pillow. Support the forearms on pillows, with the hand
slightly elevated above the forearm. Do not use the knee gatch to raise the knees.
14.
While performing a physical examination on a client, the nurse observes that the client has
scoliosis based on which of
the following?
A)
Lateral deviation of the thoracic spine
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B)
Concave curvature of the cervical spine
C)
Convex curvature of the thoracic spine
D)
Concave curvature of the lumbar spine
Ans: A
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Scoliosis is the lateral deviation of the thoracic spine. Concave curvature of the
cervical spine, convex curvature of the thoracic spine, and concave curvature of the
lumbar spine are the characteristics of a normal spinal alignment.
A)
Back of the skull
B)
Elbows
C)
Sacrum
D)
Heels
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15.
A nurse is caring for a frail older adult client with chronic obstructive pulmonary
disease. The client always remains in a sitting position to help him breathe more
easily. Based on the understanding that prolonged sitting may put pressure on
bony prominences, the nurse frequently assesses which area of this client?
Ans: C
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Feedback:
The sacrum bears the greatest pressure during a sitting position. The back of the skull,
elbows, and heels bear pressure in a supine position.
A)
Thrombophlebitis
B)
Anemia
C)
Orthostatic hypotension
D)
Bradycardia
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16.
A young adult woman has had orthopedic surgery on her right knee. The first time
she gets out of bed, she describes weakness, dizziness, and feeling faint. The nurse
correctly recognizes that which of the following conditions is likely
affecting the client?
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Orthostatic hypotension refers to a reduction in blood pressure with position changes
from lying to sitting or standing. Blood pooling in the legs increases, thus increasing
the postural hypotension. Thrombophlebiits refers to an inflammation of a the veins;
it manifests with redness and swelling. Anemia refers to a reduction in hemoglobin.
This may present with feelings of weakness. Bradycardia refers to a reduced heart
rate.
17.
Which of the following activities is normally acquired in the toddler years? Select all that
apply.
A)
Rolling over
B)
Pulling to a standing position
C)
Walking
D)
Running
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E)
Jumping
Ans: C, D, E
Feedback:
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In the toddler, gross and fine motor development continue rapidly; by 15 months,
most can walk unassisted, run, and jump. Rolling over and pulling to a standing
position are accomplished by the infant.
A)
Obtain a mechanical lateral transfer device to move the client onto a stretcher.
B)
Enlist the aid of two other staff members and pull the client across the bed and onto a
stretcher.
C)
Position a friction-reducing sheet under the client before attempting the transfer.
D)
Transport the client to the radiology department in the hospital bed.
Ans: A
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18.
The nurse cares for a newly admitted client who will soon need to be taken to the
radiology department for a CT scan. The client has a Body Mass Index (BMI) of 52.
Which of the following strategies to transport the client is most
appropriate?
Feedback:
The combined weight of the bed and client will be difficult to move safely.
Additionally, this strategy does not address the need to transfer the client onto, and
off of, equipment in the radiology department.
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A)
Have the client sit on the side of the bed for several minutes before moving to the chair.
B)
Infuse an intravenous fluid bolus 15 minutes before transferring the client into the chair.
C)
Position a friction-reducing sheet under the client.
D)
Obtain a quad cane for the client to use as a transfer aid.
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19.
The nurse is caring for a client who has been on bed rest. The primary care provider
has just written a new order for the client to sit in the chair three times a day. Which
of the following actions will be most effective to transfer the client
safely into the chair?
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Having the client sit at the side of the bed minimizes the risk for blood pressure
changes (orthostatic hypotension) that can occur with position change.
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20.
The nurse is helping a client walk in the hallway when the client suddenly reaches for the
handrail and states, “I feel so
weak. I think I am going to pass out.” Which of the following initial actions by the nurse is
appropriate?
A)
Firmly grasp the client’s gait belt.
B)
Support the client’s body against yours and gently slide the client onto the floor.
C)
Ask the client to lean against the wall while you obtain a wheelchair.
D)
Apply oxygen and wait several minutes for the weakness to pass.
E)
Ask the patient, “When was the last time you ate?”
Ans: B
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Assessing for the potential causes of the weakness should occur after the client’s safety is
assured.
A)
True
B)
False
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21.
Once applied, antiembolism stockings should not be removed until the primary care provider
writes an order to
discontinue them.
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Antiembolism stockings may be removed (for example, during morning care to
inspect the legs) without the primary care provider writing an order to discontinue
them.
A)
Face the direction of movement.
B)
Twist body at the waist when lifting.
C)
Keep body weight higher than center of gravity.
D)
Keep feet together to provide a base of support.
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22.
A nurse uses proper body mechanics to move a client up in bed. Which of the following is a
guideline for using these
techniques properly?
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Ans: A
Feedback:
When using body mechanics, the nurse should face the direction of movement and
avoid twisting the body. Maintaining balance involves keeping the spine in vertical
alignment, body weight close to the center of gravity, and feet spread for a broad base
of support.
Which of the following clients would be an appropriate candidate to move by using a powered
stand-assist device?
A)
A comatose client who is being taken for x-rays
B)
An alert client after knee replacement surgery who is being assisted to ambulate
C)
An obese client who has Alzheimer’s disease and is being escorted to the shower room
D)
A car accident victim with fractures in both legs who is being moved to another room
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23.
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Ans: B
Powered stand-assist devices can be used with clients with weight-bearing ability on
at least one leg, who can follow directions, and who are cooperative. Clients who are
unable to bear partial weight, full weight or who are uncooperative should be
transferred using a full body sling lift.
24.
A nurse is ambulating a client who catches her foot on the bed frame and begins to fall. Which
of the following is an
accurate step to prevent or minimize damage from this fall?
A)
The nurse should place his or her feet close together with one foot in front of the other.
B)
The nurse should rock his or her pelvis out on the opposite side of the client.
C)
The nurse should grasp the gait belt and pull the client’s body backward away from his or her
body.
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D)
The nurse should gently slide the client down his or her body to the floor.
Ans: D
Feedback:
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The nurse should place feet wide apart, with one foot in front and rock pelvis out on
the side nearest the client. The nurse should grasp the gait belt and support the client
by pulling his or her weight backward against his or her body, and then gently sliding
the client down his or her body to the floor, protecting the client’s head.
A)
Client restrictions
B)
Client age
C)
Client food preferences
D)
Client restraints
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25.
The nurse is preparing to move a client from bed into a wheelchair to eat lunch. What client
data would the nurse check
to see if the assistance of another nurse is needed?
Feedback:
When attempting to move a client, the nurse would first check the client’s chart to
see if the client has any physical limitations or restrictions. The nurse would also
evaluate the client’s condition and determine whether or not the client can help with
positioning or understand directions. Lastly, the nurse would evaluate the client’s
body weight and his or
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her own strength. Age and food preferences would not affect movement. Clients with
restraints still need to be moved and repositioned.
A)
Every hour
B)
Every two hours
C)
Every four hours
D)
Every shift
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26.
A nurse is repositioning a client who has physical limitations due to recent back surgery. How
often would the nurse
turn the client in bed?
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The nurse would turn the client in bed every two hours to avoid complications due to
inactivity. The nurse would also include this activity in the client plan of care.
A)
Sitting up
B)
Lying prone
C)
Lying flat
D)
Lying flat with feet raised slightly
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27.
The nurse is preparing a client to be turned in bed. In what position would the nurse place the
client to begin this
procedure?
Ans: C
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The nurse would position the bed so that the client is lying flat on his/her back and
then raise the bed to a comfortable working height. This facilitates moving the client
to the side in order to perform the turn in bed.
A)
Reverse Trendelenburg
B)
Supine
C)
Sitting
D)
Semi-Fowler’s
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28.
The nurse is preparing to move a patient up in bed with the assistance of another nurse. In
what position would the nurse
place the patient, if tolerated?
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The nurse would adjust the head of the bed to a flat position or slight Trendelenburg,
as low as the patient can tolerate. Flat positioning helps to decrease the gravitational
pull of the upper body.
29.
When moving a client up in bed, the nurse asks the client to fold the arms across the chest and
lift the head with the chin
on the chest. What is the rationale for placing the client in this position?
A)
To prevent hyperextension of the neck
B)
To prevent pressure on the arms
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C)
To lower the client’s center of gravity
D)
To decrease the effort needed to move the client
Ans: A
Feedback:
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The nurse would ask the client to fold the arms across the chest and lift the head with
the chin on the chest. Positioning in this manner provides assistance, reduces
friction, and prevents hyperextension of the neck.
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30.
When transferring a client from bed to a stretcher, the nurses working together turn the client
to position a transfer board
partially underneath the patient. What is the rationale for using a transfer board in this
procedure?
To lift the client off the bed.
B)
To slide the board with the client onto the stretcher.
C)
To reduce friction as the client is pulled laterally onto the stretcher.
D)
To protect the client’s head from hitting the headboard.
Ans: C
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A)
Feedback:
The transfer board or other lateral-assist device reduces friction, easing work load to
move the client. It is positioned partially under the client, across the space between
the bed and stretcher.
31.
When assisting a client from the bed into a wheelchair, the nurse assesses the client standing
up and notices the client is
weak and unsteady. What would be the recommended nursing intervention in this situation?
A)
Allow the client to keep standing for several minutes until balance returns.
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B)
Use the call bell to summon the assistance of another nurse.
C)
Return the client to the bed.
D)
Place the client into the wheelchair.
Ans: C
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Once the client is standing, the nurse would assess the patient’s balance and leg
strength. If the client is weak or unsteady, the nurse would return the client to the
bed.
A)
Cross the arms across the chest and keep the legs straight.
B)
Cross the arms across the chest and cross the legs.
C)
Keep the arms at the sides and the legs crossed.
D)
Keep the arms folded loosely at the abdomen and the legs straight.
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32.
Student nurses are turning a client in bed. In order to move the client to the edge of the bed,
which positioning
instruction is best to give the client when using the friction-reducing sheet?
Ans: B
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The nurse would ask the client to cross the arms across the chest, and cross the legs.
This facilitates the turning motion and protects the client’s arms during the move. Or,
if the client is able, the nurse may ask the client to assist by grasping the bed rail on
the side toward which the client is turning.
A)
Powered-stand assist
B)
Transfer chair
C)
Repositioning lift
D)
Gait belt
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33.
A nurse is assisting in the transfer of a client to a stretcher. The client has casts on both legs.
What is the nurse’s best
choice of transfer equipment for this client who cannot bear weight on either leg?
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Chairs that can convert into stretchers are available. These are useful with clients
who have no weight-bearing capacity, cannot follow directions, and/or cannot
cooperate. The back of the chair bends back and the leg supports elevate to form a
stretcher configuration, eliminating the need for lifting the client. Powered-stand
assist devices and repositioning devices require the client to have weight-bearing
capacity in one leg. Gait belts are used to assist clients to ambulate safely.
34.
While being measured for anti-embolism stockings, the client asks the nurse why they are
necessary. What would be the
nurses’s best response?
A)
They promote venous blood return to the heart.
B)
They eliminate peripheral edema.
C)
They provide a nonslip foot surface to help prevent falls.
D)
They reduce the risk for impaired skin integrity.
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Ans: A
Feedback:
Anti-embolism stockings are used to promote venous blood return to the heart and
help in preventing blood clots. They often do help with edema in the legs, but they do
not eliminate edema (nor is this their main goal). They do not provide a nonslip foot
surface. If applied incorrectly they can increase the risk for impaired skin integrity.
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The nurse and an assistant are preparing to move a client up in bed. Arrange the following
steps in the correct order.
Adjust the head of the bed to a flat position.
2.
Place a friction-reducing sheet under the client.
3.
Ask the client to bend legs and place the chin on the chest.
4.
Position the assistant on the side opposite you.
5.
Remove all pillows from under the client.
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1.
6. Grasp the sheet and move the client on the count of 3.
A)
3, 1, 2, 4, 5, 6
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35.
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B)
1, 2, 4, 3, 5, 6
C)
1, 5, 4, 2, 3, 6
D)
3, 2, 1, 4, 6, 5
E)
1, 3, 2, 4, 5, 6
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Ans: C
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This is the correct order for a nurse and an assistant who are preparing to move a client up in
bed.
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Chapter 35, Rest and Sleep
Which natural chemical does the body produce at night to decrease wakefulness and promote
sleep?
A)
Melatonin
B)
Serotonin
C)
Endorphins
D)
Dopamine
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Ans: A
Feedback:
Melatonin is a natural chemical produced at night that decreases wakefulness and promotes
sleep.
2.
A client reports that her naps after lunch often stretch to three hours in length and that she has
great difficulty rousing
herself after a nap. This condition is best termed as which of the following?
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A)
Hypersomnia
B)
Insomnia
C)
Parasomnia
D)
Sleep apnea
Ans: A
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Hypersomnia is a condition characterized by excessive sleep, particularly during the
day. Insomnia is characterized by difficulty falling asleep, intermittent sleep, or early
awakening from sleep. Parasomnias are patterns of waking behavior that appear
during sleep. Sleep apnea is a condition in which a person experiences the absence of
breathing, or diminished breathing efforts, during sleep (between snoring intervals).
A)
“Most adults need between seven and nine hours, but everyone is different.”
B)
“It’s important to get a minimum of eight hours sleep each night.”
C)
“More sleep equals better health, so the more sleep you can fit into your schedule, the better.”
D)
“Sleep needs depend a lot on age, and at your age, six to seven hours usually suffice.”
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3.
A client in his 40s has asked the nurse how much sleep he should be getting in order to
maximize his health and wellbeing. How should the nurse respond?
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Ans: A
Feedback:
Sleep needs and routines are highly individual, but most adults require between seven and nine
hours of sleep.
A)
A client who receives IV antibiotics every three hours
B)
A client whose opioid analgesics result in central nervous system depression
C)
A client who is receiving corticosteroids that make her feel restless and agitated
D)
A client whose physical therapy has been scheduled in the late evening
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4.
Which of the following clients likely faces a risk for the nursing diagnosis of Disturbed Sleep
Pattern: Difficulty
Remaining Asleep?
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A client who requires medications throughout the night is likely to experience the
frequent awakenings associated with Disturbed Sleep Pattern: Difficulty Remaining
Asleep. Drowsiness or agitation as a result of medications may affect sleep, but are
less likely to result in mid-sleep awakenings. A client who performs physical activity
prior to bedtime may have difficulty falling asleep.
5.
Which group of terms best describes sleep?
A)
Decreased state of activity, refreshed
B)
Altered consciousness, relative inactivity
C)
Comatose, immobility
D)
Alert, responsive
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Ans: A
Ans: B
Feedback:
Sleep is a state of rest accompanied by altered consciousness and relative inactivity.
Rest is a condition in which the body is in a decreased state of activity.
An individual awakens from a sound sleep in the middle of the night because of abdominal
pain. Why does this happen?
A)
Stimuli from peripheral organs to the RAS
B)
Stimuli to the wake center in the cerebral cortex
C)
Messages from chemoreceptors to the brain
D)
Messages from baroreceptors to the spinal cord
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6.
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Ans: A
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The reticular activating system (RAS) facilitates reflex and voluntary movements as
well as cortical activities related to a state of alertness. Wakefulness occurs when the
RAS experiences stimuli (including pain) from peripheral organs and cells.
7.
A nurse is caring for a client who is sleeping for abnormally long periods of time. This
condition may be caused by
injury to which of the following body structures?
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A)
Spinal cord
B)
Pancreas
C)
Hypothalamus
D)
Thyroid
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Ans: C
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The hypothalamus has control centers for several involuntary activities of the body,
one of which concerns sleeping and waking. Injury to the hypothalamus may cause a
person to sleep for abnormally long periods.
What name is given to the rhythmic biologic clock that exists in humans?
A)
Sleep-wake cycle
B)
Alert-unaware process
C)
Circadian rhythm
D)
Yo-yo theory
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Ans: C
Feedback:
Rhythmic biologic clocks are known to exist in plants, animals, and humans.
Circadian rhythms complete a full cycle every 24 hours and in humans affect heart
rate, blood pressure, body temperature, hormone secretions, and metabolism, as well
as performance and mood.
9.
A nurse working the night shift assesses a client’s vital signs at 4 a.m. (0340). What would be
the expected findings,
based on knowledge of NREM sleep?
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A)
Decreased TPR and BP
B)
Increased TPR and BP
C)
No change from daytime readings
D)
Highly individualized, cannot predict
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Ans: A
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Throughout the stages of NREM sleep, the parasympathetic nervous system
dominates; decreases in temperature, pulse, respirations, and blood pressure occur.
A)
Prone position increases the risk for sudden infant death syndrome.
B)
Prone position decreases the risk for sudden infant death syndrome.
C)
Supine position may alter the size and shape of the infant’s head.
D)
Supine position makes changing diapers and feeding difficult.
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10.
A nurse educates a young couple on putting their newborn on his back to sleep. What is the
rationale for this
information?
Ans: A
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Feedback:
Newborns sleep an average of 16 out of every 24 hours. It is important to teach
parents to position an infant on the back. Sleeping in the prone position increases the
risk for sudden infant death syndrome (SIDS).
A)
Neonephrine
B)
Seratonin
C)
Melatonin
D)
Dopamine
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11.
Based on the circadian cycle, the body prepares for sleep at night by decreasing the body
temperature and releasing
which chemical?
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Based on the circadian cycle, the body prepares for sleep at night by decreasing the
body temperature and releasing melatonin (a natural chemical produced at night that
decreases wakefulness and promotes sleep).
12.
A middle-age adult man has just started an exercise program. What would the nurse teach him
about timing of exercise
and sleep?
A)
Exercising immediately before bedtime enhances ability to sleep
B)
Exercising within two hours of bedtime can hinder ability to sleep
C)
The time of day does not matter; exercise facilitates sleep
D)
The fatigue from exercise may be a hindrance to sleep
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Ans: B
Feedback:
Moderate exercise is a healthy way to promote sleep, but exercise that occurs within a
two-hour interval before normal bedtime can hinder sleep.
Which medication is least likely to affect sleep quality?
A)
Diuretic
B)
Steroid
C)
Antidepressant
D)
Ambien
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Sleep quality is influenced by drugs. Drugs that decrease sleep include diuretics,
steroids, and antidepressants. Ambien and chloral hydrate appear to influence the
quality of sleep least and promote normal sleep.
14.
Which individual is likely to require more hours of sleep?
A)
a person 75 years of age
B)
a person 43 years of age
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C)
a person 25 years of age
D)
a person 15 years of age
Ans: D
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Despite individual variations, growing children, especially adolescents who are in a
tremendous growth period, require from 10 to 14 hours of sleep per night. This is in
comparison with the accepted standard for adults, which is 8 hours. Older adults often
require less sleep.
A)
No, snoring has varied patterns
B)
No, this is a description of normal snoring
C)
Yes, this is an indicator of obstructive apnea
D)
Yes, the bed partner is unable to sleep at night
Ans: C
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15.
A client’s bed partner reports the client often has irregular snoring and silence followed by a
snort. Does this warrant
further assessment?
Feedback:
Snoring is caused by an obstruction to airflow through the nose and mouth. When
snoring changes from the characteristic sawing wood sound to a more irregular
silence followed by a snort, this indicates obstructive apnea.
16.
Which of the following is the most common sleep disorder?
A)
Hypersomnia
B)
Parasomnia
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C)
Insomnia
D)
Dyssomnia
Ans: C
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Insomnia is characterized by difficulty falling asleep, intermittent sleep, or early
awakening from sleep. It is the most common of all sleep disorders.
A)
Use the bedroom for sleep and sex only.
B)
Use the bedroom for reading and eating.
C)
Go to bed at the same time every night.
D)
Sleep alone with minimal coverings.
Ans: A
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17.
A client who has a sleep disorder is trying stimulus control to improve amount and quality of
sleep. What is
recommended in this type of therapy?
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Stimulus control involves using the bedroom for sleep and sex only. If not asleep
within 15 to 20 minutes, the person should leave the room and return only when he or
she feels sleepy. Getting up at the same time every day is also recommended.
A client is diagnosed with narcolepsy. Which of the following is a characteristic of this
disorder?
A)
Waking during sleep
B)
Restless leg syndrome
C)
Uncontrollable desire to sleep
D)
Decrease in the amount or quality of sleep
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Narcolepsy is a condition characterized by an uncontrollable desire to sleep.
Narcolepsy is considered a neurologic disorder.
A client with a sleep disorder experiences cataplexy. Which is a feature of this condition?
A)
Irresistible urge to sleep, regardless of the type of activity in which the client is engaged
B)
Sudden loss of motor tone that may cause the person to fall asleep; usually experienced during
a period of strong
emotion
C)
Nightmare or vivid hallucinations experienced during sleep time
D)
Skeletal paralysis that occurs during the transition from wakefulness to sleep
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Ans: B
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Cataplexy is the sudden loss of motor tone that may cause the person to fall asleep;
this is usually experienced during a period of strong emotion. Sleep attacks are
irresistible urges to sleep, regardless of the type of activity in which the client is
engaged. Hypnagogic hallucinations involve nightmares or vivid hallucinations. In
sleep-onset REM periods, during a sleep attack, the person moves directly into REM
sleep. Sleep paralysis is skeletal paralysis that occurs during the transition from
wakefulness to sleep.
What is the rationale for using CPAP to treat sleep apnea?
A)
Positive air pressure holds the airway open.
B)
Negative air pressure holds the airway closed.
C)
Delivery of oxygen facilitates respiratory effort.
D)
Alternating waves of air stimulate breathing.
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20.
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Ans: A
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Continuous positive airway pressure (CPAP) is used to treat sleep apnea. The device,
worn at night, delivers positive air pressure through a facemask to hold the airway
open.
21.
The parents of a boy 10 years of age are worried about his sleepwalking (somnambulism).
What topic should the nurse
discuss with the parents?
A)
Sleep deprivation
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B)
Privacy
C)
Schoolwork
D)
Safety
Ans: D
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Somnambulism (sleepwalking) is a parasomnia, a pattern of waking behaviour that
appears during sleep. It is more commonly seen in children and is commonly
outgrown before adulthood. Safety and prevention of injury are paramount concerns.
What independent nursing action can be used to facilitate sleep in hospitalized clients who are
on bedrest?
A)
Administering prescribed sleep medications
B)
Changing the bed with fresh linens
C)
Encouraging naps during the daytime
D)
Giving a back massage
Ans: D
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22.
Feedback:
Simple interventions, such as offering a back massage, can promote comfort and sleep in
hospitalized clients on bedrest.
23.
A sedative-hypnotic has been prescribed to help a client sleep. What should the nurse teach
the client about this
medication?
A)
It should be taken every night for several months
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B)
It is useful for sleep but is better taken with alcohol
C)
It loses its effectiveness after one or two weeks
D)
It should be taken in the morning for long-term effects
Ans: C
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Although most sedative-hypnotics provide several nights of excellent sleep, the
medication often loses its effect after one or two weeks. Caution the client not to
increase the dose or take the drug with alcohol to try to increase effect.
What is the most common method for ordering sleep medications?
A)
Stat
B)
p.r.n
C)
Single order
D)
Daily dose
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24.
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Sleep medications are often ordered on a p.r.n. (as needed) basis. These medications
should be administered only when indicated, and always with the full knowledge of
their limitations.
A)
Obesity
B)
Anxiety
C)
Diabetes
D)
Hypertension
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25.
What condition have studies confirmed occurs when adults and children do not get
recommended hours of sleep at
night?
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The fact that children and adults are getting less sleep has been implicated as a
contributing factor to the obesity epidemic in the United States (CDC, 2008,
Goldsmith, 2007). Various studies confirm that adults and children who slept less
than their recommended hours per night were more likely to be overweight. This
sleep-weight link is possibly related to two hormones: leptin and ghrelin. Leptin
signals the brain to stop eating, whereas ghrelin promotes continued eating. Research
suggests that sleep deprivation lowers leptin levels and elevates ghrelin levels, thus
increasing one’s appetite.
26.
Which drug normalizes sleep cycles by enabling the body’s supply of melatonin to naturally
promote sleep?
A)
Flurazepam (Dalmane)
B)
Temazepam (Restoril)
C)
Eszopiclone (Lunesta)
D)
Ramelteon (Rozerem)
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Ans: D
Feedback:
The most recently approved sleep medication is Ramelteon (Rozerem). This drug is
classified as a melatonin receptor agonist and it normalizes sleep cycles by enabling
the body’s supply of melatonin to naturally promote sleep (Goldsmith, 2007).
Which expected outcome demonstrates the effectiveness of a plan of care to promote rest and
sleep?
A)
Verbalizes inability to sleep without medications
B)
Continues to read in bed for hours each night
C)
Identifies factors that interfere with normal sleep pattern
D)
Reports minimal improvement in quality of rest and sleep
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The nurse evaluates the effectiveness of the plan of care to promote rest and sleep by
evaluating if the client has met the expected outcomes of the plan. If the client is able
to identify factors that interfere with normal sleep patterns, this illustrates
achievement of one expected outcome.
28.
A nurse is caring for a client who has been diagnosed with insomnia. What nursing
intervention would help the nurse
relieve the client’s condition?
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A)
Maintain a calm and quiet environment free from noise.
B)
Administer sedatives as prescribed by the physician.
C)
Motivate the client to sleep because it may affect his health.
D)
Engage the client in some diversional activities.
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Maintaining a calm and quiet environment is the most appropriate nursing activity to
relieve insomnia. Motivating the client to sleep by telling him that it may affect his
health may cause anxiety in the client. Engaging the client in diversional activities at
bedtime may increase sleeplessness. Sedatives can be administered as prescribed,
but they should be used as last resort. These activities may not relieve insomnia in
the client.
A)
Encourage the client to lose weight.
B)
Avoid sedatives for sleeping.
C)
Encourage deep breathing exercises.
D)
Provide good ventilation in the room.
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29.
A nurse is caring for a client diagnosed with sleep apnea. What should the nurse do in order to
promote sleep in the
client?
Ans: B
Feedback:
The nurse should avoid sedatives in the client because sedatives may depress
respiration. The client with sleep apnea already has decreased ventilation and low
blood oxygenation; the condition may become worse if the respiration is further
depressed by sedatives. Losing weight is a long-term measure and is not applicable
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in this case. Encouraging deep breathing exercises and providing good ventilation
may help the client,
but they are secondary measures.
A)
Nasal catheter
B)
Oxygen tent
C)
Transtracheal oxygen
D)
CPAP mask
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30.
A nurse is caring for a client who complains about sleep apnea. Which of the following
delivery devices should the
nurse use to administer oxygen to this client?
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The nurse should use a CPAP mask for a client with complaints of sleep apnea. A
CPAP mask maintains positive pressure within the airway throughout the respiratory
cycle. Clients generally wear this type of mask at night to maintain oxygenation
when they experience sleep apnea. A nasal catheter is a tube for delivering oxygen
that is inserted through the nose into the posterior nasal pharynx. It is used for clients
who tend to breathe through the mouth or experience claustrophobia when a mask
covers their face. An oxygen tent is a clear plastic enclosure that provides cooled,
humidified oxygen, which is used for active toddlers. Transtracheal oxygen is a
hollow tube inserted within the trachea to deliver oxygen to clients who require
long-term oxygen therapy.
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Which of the following guidelines does the nurse apply to discussion of sleep patterns with
older adult clients?
A)
Circadian rhythms become more prominent as clients age.
B)
The amount of stage 4 sleep increases as clients age.
C)
Total sleep time decreases as the clients age.
D)
Older clients fall asleep more quickly than younger ones.
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As people age, the amount of stage 4 sleep decreases significantly. Sleeping patterns
may become polyphasic, with a shorter nocturnal period plus daytime naps.
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32.
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A client has sought care because of insomnia that has been increasing in severity and
frequency in recent months. What
questions should the nurse include in an assessment of this client’s health problem? Select all
that apply.
“Do you have a family history of sleep disturbances?”
B)
“Do you smoke?”
C)
“What medications are you currently taking?”
D)
“Do you have a consistent routine around getting ready for bed and going to bed?”
E)
“How would you characterize your mood lately?”
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A)
Ans: B, C, D, E
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Sleep is a multifaceted phenomenon that is affected by many variables. Among these
are cigarette smoking, medications, sleep routines, and mood; the nurse should
assess each of these areas. Sleep problems do not normally have a genetic basis.
A new mother is discussing her 6-month-old infant’s sleep habits and expresses
concern about the infant obtaining too much sleep. The mother reports the infant’s
circadian cycle as:
Time period
Activity
awake
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0600-0900
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33.
sleep
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0900-1100
awake
1600-1900
1900-2200
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1300-1600
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1100-1300
sleep
awake
sleep
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2200-2400
awake
2400-0600
sleep
The best statement by the nurse is:
“Your infant requires more time asleep during the day hours.”
B)
“You need to awaken your infant during the 2400 to 0600 time period.”
C)
“Your infant is obtaining the average hours of sleep per day for an infant.”
D)
“Your infant is actually obtaining too little sleep for one day.”
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A)
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Ans: C
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Infants usually require 14 to 20 hours of sleep per day. This infant is obtaining 14 hours of
sleep each day.
34.
The nurse manager in an acute care facility has received client evaluations in
which the clients have complained about excessive noise that interfered with their
rest. The nurse manager and nursing staff plan to do the following.
Which activity will most assist clients in obtaining rest?
A)
Post signs for quiet and turn down hall lights during formal quiet times.
B)
Ensure clients are offered prescribed sleeping medications at bedtime.
C)
Provide a small carbohydrate snack or juice prior to hours of sleep.
D)
Adjust the temperature of the room to 74 degrees and provide a blanket.
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Ans: A
Feedback:
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All of the options may be helpful in promoting rest. However, the client
complaints are about excessive noise, and posting signs for quiet and turning down
hall lights during formal quiet times is the only option that directly addresses
noise. Also, some clients cannot rest if the room temperature is not to their liking.
The room temperature needs to be adjusted to client preference.
A)
“How loud is his snoring?”
B)
“Is there silence after snoring which then is followed with a snort?”
C)
“How long does he snore each night?”
D)
“How often are you awakened at night due to his loud snoring?”
Ans: B
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35.
The client is a male who states his wife complains that his snoring awakens her at night. The
spouse is present. To
obtain further data, the nurse asks the spouse what?
Feedback:
Snoring that is followed by silence and then a snort may be a sign of obstructive
apnea. Snoring is not considered a sleeping disorder and is often more disturbing to
the sleep partner.
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Chapter 36, Comfort
A)
Somatic pain
B)
Cutaneous pain
C)
Visceral pain
D)
Phantom pain
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1.
A cyclist reports to the nurse that he is experiencing pain in the tendons and ligaments of his
left leg, and the pain is
worse with ambulation. The nurse will document this type of pain as which of the following?
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Somatic pain is diffuse or scattered pain, and it originates in tendons, ligaments,
bones, blood vessels, and nerves. Cutaneous pain usually involves the skin or
subcutaneous tissues. Visceral pain is poorly localized and originates in body organs.
Phantom pain occurs in an amputated leg for which receptors and nerves are clearly
absent, but the pain is a real experience for the client.
Which statement accurately describes pain experienced by the older adult?
A)
Boredom and depression may affect an older person’s perception of pain.
B)
Residents in long-term care facilities have a minimal level of pain.
C)
The older client has decreased sensitivity to pain.
D)
A heightened pain tolerance occurs in the older adult.
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Ans: A
Feedback:
Boredom, loneliness, and depression may affect an older person’s perception and
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report of pain. One myth held by many to be true is that older clients have a
decreased sensitivity to pain and therefore a heightened pain tolerance. Numerous
older adult clients residing in long-term care facilities have significant pain that
negatively affects their quality of life.
3.
Pet therapy is commonly used in long-term facilities for distraction. If a client is experiencing
pain and the pain is
temporarily decreased while petting a visiting dog or cat, this is an example of which type of
distraction technique?
Tactile kinesthetic distraction
B)
Visual distraction
C)
Auditory distraction
D)
Project distraction
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Examples of tactile kinesthetic distraction include holding or stroking a loved one,
pet, or toy; rocking; and slow rhythmic breathing. Project distraction includes
playing a challenging game or performing meaningful work. Visual distraction can
be accomplished through reading or watching television. Auditory distraction may
occur when one listens to music.
Of the following individuals, who can best determine the experience of pain?
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A)
The person who has the pain
B)
The person’s immediate family
C)
The nurse caring for the client
D)
The physician diagnosing the cause
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Ans: A
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According to McCaffery, an expert on pain, “Pain is whatever the experiencing
person says it is, existing whenever he (or she) says it does.” The only one who can
be a real authority on whether and how a person experiences pain is that individual.
A client who has breast cancer is said to be in remission. What does this term signify?
A)
The client is experiencing symptoms of the disease.
B)
The client has end-stage cancer.
C)
The client is experiencing unremitting pain.
D)
The disease is present but the client is not experiencing symptoms.
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Ans: D
Feedback:
Commonly, people with chronic pain experience periods of remission (when the
disease is present but the person does not experience symptoms) or exacerbation (the
symptoms reappear).
6.
Which of the following clients would be classified as having chronic pain?
A)
A client with rheumatoid arthritis
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B)
A client with pneumonia
C)
A client with controlled hypertension
D)
A client with the flu
Ans: A
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Chronic pain is pain that may be limited, intermittent, or persistent but that lasts
beyond the normal healing period. Acute pain is generally rapid in onset and varies
in intensity from mild to severe. After its underlying cause is resolved, acute pain
disappears. It should end once healing occurs.
A)
Psychogenic pain
B)
Neuropathic pain
C)
Cutaneous pain
D)
Visceral pain
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7.
A client has a severe abdominal injury with damage to the liver and colon from a motorcycle
crash. What type of pain
will predominate?
Ans: D
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Feedback:
Visceral pain is poorly localized and originates in body organs in the thorax, cranium,
and abdomen. The pain occurs as organs stretch abnormally and become distended,
ischemic, or inflamed.
A)
Cutaneous pain
B)
Referred pain
C)
Allodynia
D)
Nociceptive
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8.
A client in the emergency department is diagnosed with a myocardial infarction (heart attack).
The client describes pain
in his left arm and shoulder. What name is given to this type of pain?
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Ans: B
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Referred pain is pain that is perceived in an area distant from the point of origin.
Pain associated with a myocardial infarction is frequently referred to the neck,
shoulder, or arm.
9.
Why is acute pain said to be protective in nature?
A)
It warns an individual of tissue damage or disease.
B)
It enables the person to increase personal strength.
C)
As a subjective experience, it serves no purpose.
D)
As an objective experience, it aids diagnosis.
Ans: A
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Feedback:
Pain is a subjective experience. Acute pain, lasting from a few minutes to less than
six months, warns an individual of tissue damage or organic disease. After its
underlying cause is resolved, acute pain disappears.
A)
Complex regional pain syndrome
B)
Postherpetic neuralgia
C)
Trigeminal neuralgia
D)
Diabetic neuropathy
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10.
A client tells the nurse that she is experiencing stabbing pain in her mouth, gums, teeth, and
chin following brushing her
teeth. These are symptoms of which of the following pain syndromes?
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Ans: C
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A symptom of trigeminal neuralgia is paroxysms of lightning-like stabs of in tense
pain in the distribution of one or more divisions of the trigeminal nerve, the fifth
cranial nerve. Pain is usually experienced in the mouth, gums, lips, nose, cheek, chin,
and surface of the head and may be triggered by everyday activities like talking,
eating, shaving, or brushing one’s teeth.
11.
A nurse implements a back massage as an intervention to relieve pain. What theory is the
motivation for this
intervention?
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A)
Gate control theory
B)
Neuromodulation
C)
Large/small fiber theory
D)
Prostaglandin stimulation
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The gate control theory of pain describes the transmission of painful stimuli. Nursing
interventions, such as massage or a warm compress to a painful lower back, stimulate
large nerve fibers to close the gate, thus blocking nerve impulses from that area.
A)
Narcotics
B)
Sedatives
C)
A-delta fibers
D)
Endorphins
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12.
A client has been taught relaxation exercises before beginning a painful procedure. What
chemicals are believed to be
released in the body during relaxation to relieve pain?
Ans: D
Feedback:
Endorphins, which are opioid neuromodulators, are produced at neural synapses at
various points in the CNS pathway. They have prolonged analgesic effects and
produce euphoria. It is suggested that they may be released when measures such as
skin stimulation and relaxation techniques are used.
13.
How may a nurse demonstrate cultural competence when responding to clients in pain?
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A)
Treat every client exactly the same, regardless of culture.
B)
Be knowledgeable and skilled in medication administration.
C)
Know the action and side effects of all pain medications.
D)
Avoid stereotyping responses to pain by clients.
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Ans: D
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Culture influences an individual’s response to pain. It is particularly important to
avoid stereotyping responses to pain because the nurse frequently encounters clients
who are in pain or anticipating it will develop. A form of pain expression that is
frowned upon in one culture may be desirable in another cultural group.
Which client would be most likely to have decreased anxiety about, and response to, pain as a
result of past experiences?
A)
One who had pain but got adequate relief
B)
One who had pain but did not get relief
C)
One who has had chronic pain for years
D)
One who has had multiple pain experiences
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Ans: A
Feedback:
An individual’s experience of pain in the past, and the qualities of that experience,
profoundly affect new pain experiences. Some clients have experienced severe acute
or chronic pain in the past but received immediate and adequate pain relief. These
clients are generally unafraid of pain and initiate appropriate requests for assistance.
Which misconception is common in clients in pain?
A)
“I will get addicted to pain medications.”
B)
“I need to ask for pain medications.”
C)
“The nurses are here to help relieve the pain.”
D)
“I do not have to fight the pain without help.”
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15.
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Ans: A
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Feedback:
Many misconceptions interfere with the client’s ability to communicate pain. A
common misconception is that “if I ask for something for pain, I may become
addicted to the medication.”
16.
What is the term used to describe a pharmaceutical agent that relieves pain?
A)
Antacid
B)
Antihistamine
C)
Analgesic
D)
Antibiotic
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Ans: C
Feedback:
An analgesic is a pharmaceutical agent that relieves pain. Analgesics reduce the
perception of pain and alter responses to discomfort.
A)
“Only take morphine when you have the most severe pain.”
B)
“Increase fluids and high-fiber foods, and use a mild laxative.”
C)
“Administer an enema to yourself every third day.”
D)
“Constipation is nothing to worry about; take your medicine.”
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17.
A client with cancer pain is taking morphine for pain relief. Knowing constipation is a
common side effect, what would
the nurse recommend to the client?
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Ans: B
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The most common side effects associated with opioids (e.g., morphine) are sedation,
nausea, and constipation. If constipation persists, it usually responds to treatment with
increased fluids and fiber, and use of a mild laxative.
18.
Which client would benefit from a p.r.n. drug regimen?
A)
One who had thoracic surgery 12 hours ago
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B)
One who had thoracic surgery four days ago
C)
One who has intractable pain
D)
One who has chronic pain
Ans: B
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A p.r.n. drug regimen has not proven effective for people experiencing acute pain,
such as in the early postoperative period. It is not adequate for clients with
intractable or chronic pain. However, later in the postoperative period, it may be
acceptable to relieve occasional pain episodes.
A)
“You don’t have to do anything. The machine does it all.”
B)
“I will teach your family what they need to do.”
C)
“When you push the button, you will get the medicine.”
D)
“The medicine is going into your body all the time.”
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19.
A nurse is teaching an alert client how to use a PCA system in the home. How will she explain
to the client what he must
do to self-manage pain?
Ans: C
Feedback:
When the sensation of pain occurs, the client pushes a button that activates the PCA
device to deliver a small preset bolus dose of the analgesic. A lockout interval
(usually 5 to 10 minutes) prevents reactivation of the pump and administration of
another dose during that period of time. Other safeguards also limit the possibility of
overmedication.
A middle-age client is complaining of acute joint pain to a nurse who is assessing the client’s
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pain in a clinic. Which of
the following questions related to pain assessment should the nurse ask the client?
A)
Does your diet include red meat and poultry products?
B)
Does your pain level change after taking medications?
C)
Are your family members aware of your pain?
D)
Have you thought of the effects of your condition on your family?
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Ans: B
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The nurse should ask direct and specific questions about the nature of the pain and
whether it changes with medication, as this helps the nurse to quickly gather
objective data about the client’s pain. The nurse should avoid asking irrelevant and
closed-ended questions, such as whether the client’s diet includes red meat and
poultry products, or whether the client has thought about the effects of his condition
on his family. These types of questions do not add any value to pain assessment, but
could make the client feel more depressed and uncomfortable.
A)
Chronic pain will lead to psychological imbalance.
B)
Chronic pain has far-reaching effects on the client.
C)
Chronic pain can be severe in its initial stages.
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21.
A client having acute pain tells the nurse that her pain has gradually reduced, but that she fears
it could recur and
become chronic. What is a characteristic of chronic pain?
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D)
Chronic pain eases with healing and eventually disappears.
Ans: B
Feedback:
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Chronic pain has far-reaching effects on the client because the discomfort lasts longer
than six months. Chronic pain is not as severe in the initial stage as acute pain, but
does not disappear eventually with pain medication. Chronic pain need not always
lead to psychological imbalance.
A)
Blood group
B)
Anxiety level
C)
Pain level
D)
Glucose level
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22.
A nurse is assessing a client with arthritis. Which of the following should the nurse consider in
the initial assessment of
the client?
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Ans: C
Feedback:
The nurse should first assess the client’s pain level since the client has arthritis.
Anxiety level, blood group, and glucose level are not vital signs which will help the
nurse assess the client’s pain during the initial assessment.
23.
A nurse is caring for a client with acute back pain. When should the nurse assess the client’s
pain?
A)
Six hours after administering a prescribed analgesic
B)
After the client is discharged from the health care facility
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C)
Once per day when the pain is a potential problem
D)
Whenever the vital signs are measured and documented
Ans: D
Feedback:
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The nurse should assess the client’s pain whenever the nurse measures and
documents vital signs. When administering a prescribed analgesic, the nurse should
assess pain before implementing a pain-management intervention, and again 30
minutes later. The nurse should assess the client’s pain when the client is admitted to,
not discharged from, the health care facility. Similarly, the nurse should assess pain
once per shift when pain is an actual or potential problem.
A)
Provide the client with pain medication
B)
Tell the client that the pain cannot be severe
C)
Document and ask the client to wait one hour
D)
Contact the physician for a change in medication
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24.
A client has an order for a narcotic analgesic every three to four hours and he
received his last dose three hours earlier. Which of the following actions is most
appropriate for the nurse to take in response to the client’s request for pain
medication on his first postoperative day?
Ans: A
Feedback:
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Inadequate or poor pain assessment is a leading factor in poor pain control, because
the health care professional may not know a client has pain. The nurse must provide
the next dose of pain medication.
Besides controlling pain of the post-abdominal surgery client with narcotics, the nurse
suggests to the client that he …
A)
focus on pain relief
B)
use distraction
C)
describe the pain
D)
think about the next dose
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Distraction is useful when clients are undergoing brief periods of sharp, intense pain,
such as dressing changes, wound débridement, biopsy, or incident pain from shifting
positions.
A)
Teach all clients to use a pain rating scale.
B)
Determine a pain-rating goal with each client.
C)
Use pharmacologic pain relief measures first.
D)
Manipulate factors that affect the pain experience.
E)
Keep the primary care provider in charge of all pain relief measures.
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26.
The Joint Commission supports the client’s right to pain management, and published
standards for assessment and management of pain in hospitals, ambulatory care
settings, and home care settings (Joint Commission, 2008b). Which of
the following are recommended guidelines for pain management? Select all that apply.
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Ans: A, B, D
Feedback:
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The Joint Commission recommendations include teaching all clients to use a painrating scale and determining a pain- rating goal with each client. Nursing
interventions to achieve this goal include establishing a trusting nurse–patient
relationship; manipulating factors that affect the pain experience; initiating
nonpharmacologic pain relief measures; managing pharmacologic interventions;
reviewing additional pain control measures; ensuring ethical and legal responsibility
to relieve pain; and educating the client about pain.
A)
“The mild electrical impulses block the pain signal before it can reach the brain.”
B)
“The electrode patches generate heat and decrease muscle tension.”
C)
“The machine tricks the mind into believing the pain does not exist.”
D)
“The electricity produces numbness and alters tissue sensitivity.”
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27.
The nurse talks with a client who states, “My primary care provider wants me to try a TENS
unit for my pain. How can
electricity decrease my pain?” Which of the following responses is most appropriate?
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Ans: A
Feedback:
This statement explains the use of cold therapy for pain.
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28.
The nurse is caring for a client who is receiving morphine via a patient-controlled
analgesia (PCA) pump. The nurse notes that the client’s respiratory rate is 10 breaths
per minute. The client is somnolent, with minimal response to
physical stimulation. The nurse should prepare to administer which of the following
medications?
Intravenous naloxone (Narcan)
B)
Intravenous flumazenil (Romazicon)
C)
Oral modafinil (Provigil)
D)
Nebulized albuterol (Proventil)
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A)
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Ans: A
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Albuterol is a bronchodilator and not appropriate for this clinical situation.
A)
Verify the settings with another nurse.
B)
Document implementation of the PCA on the client’s chart.
C)
Attach the PCA pump tubing to the client’s intravenous access device.
D)
Check the pump’s electrical cords for cracks, splits, or fraying.
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29.
The nurse has just completed programming of a patient-controlled analgesia (PCA) pump
using prescribed parameters.
Which of the following actions should you take next?
Ans: A
Feedback:
This action should be performed before programming is initiated.
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A)
TENS is an invasive technique for providing pain relief.
B)
TENS involves the electrical stimulation of large-diameter fibers to inhibit the transmission of
painful impulses carried
over small-diameter fibers.
C)
TENS is most beneficial when used to treat pain that is generalized.
D)
A TENS unit is applied intermittently throughout the day and should not be worn for extended
periods of time.
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30.
A nurse is ordered to apply a transcutaneous electrical nerve stimulation (TENS) unit to a
client recovering from
abdominal surgery. Which of the following is a consideration when using this device?
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Ans: B
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Transcutaneous electrical nerve stimulation (TENS) is a noninvasive technique for
providing pain relief that involves the electrical stimulation of large-diameter fibers to
inhibit the transmission of painful impulses carried over small-diameter fibers. It is
most beneficial when the pain is localized and the unit can be worn for extended
periods of time.
A)
Decreased pulse and respirations
B)
Increased pulse and blood pressure
C)
Increased temperature
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31.
A nurse is assessing the vital signs of a client who is moaning due to the acute onset of pain.
What would be the
expected objective findings?
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D)
No change from client’s norms
Ans: B
Feedback:
A client who is in acute pain will most often also have an increased pulse and blood pressure.
A)
Pain Assessment in Advanced Dementia (PAINAD)
B)
Wong-Baker Faces scale
C)
Linear Scale
D)
Numeric Scale
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32.
A nurse is assessing a mentally challenged, adult client who is in pain after a fall. Which of
the following scales should
the nurse use to assess the client’s pain?
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Ans: A
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The nurse should use the Pain Assessment in Advanced Dementia (PAINAD) scale,
which was developed for cognitively impaired clients. The Wong-Baker FACES
scale is best for children and clients who are culturally diverse. Nurses generally use
a numeric scale, a word scale, or a linear scale to quantify the pain intensity of adult
clients who can express their pain intensity in words, numbers, or linear fashion with
the help of the respective scales.
33.
The nurse is caring for a client with terminal bone cancer. The client states, My pain is getting
worse and worse, and the
morphine doesn’t help anymore. The nurse determines the client’s pain is which of the
following?
A)
Acute
B)
Chronic malignant
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C)
Diffuse
D)
Intractable
Ans: D
Feedback:
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Chronic malignant pain is acute pain episodes, persistent chronic pain, or both,
associated with a progressive malignant- type process.
A)
Duration
B)
Location
C)
Chronology
D)
Intensity
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34.
A nurse asks a client to rate his pain on a scale of 0 to 10, with 0 being no pain and 10 being
worst pain. What
characteristic of pain is the nurse assessing?
Feedback:
When a nurse asks a client to rate his pain on a scale of 0 to 10, the intensity of the
pain is being assessed. Duration is how long the pain has lasted, and location is the
site of the pain.
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A)
“Oh, he probably was just hungry and wet. Did you feed him?”
B)
“Babies at that age cry at night. Think nothing of it.”
C)
“That means his ear hurt. Bring him in to be checked.”
D)
“That probably means he had a tummy ache. How is he now?”
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35.
A mother calls the nurse practitioner to say, “I don’t know what is wrong with my baby. He
cried all night and kept
pulling at his ear.” How would the nurse respond?
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Ans: C
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Pain is frustrating for children because they are unable to understand the concept and
cause of pain, and may have difficulty describing it. Crying and touching/grabbing
the painful body part are observations that may indicate pain in a child.
Chapter 37, Nutrition
A)
Carbohydrates, protein, and lipids
B)
Vitamins, minerals, and water
C)
Carbohydrates, protein, and water
D)
Lipids, vitamins, and minerals
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1.
A dietitian is providing an in-service for the nurses on a medical-surgical unit. During
the in-service, she informs the group that there are six classes of nutrients, and three
supply the body with energy. What are the three sources of
energy?
Ans: A
Feedback:
Of the six classes of nutrients, three supply energy (carbohydrates, protein, and
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lipids), and three are needed to regulate body processes (vitamins, minerals, and
water).
A)
Infection
B)
Advanced age
C)
Prolonged fasting
D)
Long periods of sleep
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2.
In planning to meet the nutritional needs of a critically ill client in the intensive care unit,
which factor will increase the
client’s basal metabolic rate?
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Ans: A
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Factors that increase a person’s basal metabolic rate (BMR) include growth,
infections, fever, emotional tension, extreme environmental temperatures, and
elevated levels of certain hormones (epinephrine and thyroid hormones). Aging,
prolonged fasting, and sleep all decrease BMR.
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3.
A client is interested in losing 15 pounds, and she informs the nurse she is counting
her calorie intake each day. The client has a goal of losing one pound a week until
she reaches her goal. The client asks the nurse how many calories she
should decrease daily to lose a pound a week. What is the nurse’s best response?
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A)
500 calories/day
B)
200 calories/day
C)
300 calories/day
D)
400 calories/day
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Ans: A
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To lose 1 pound (0.45 kg) in a week, daily calorie intake should be decreased by 500
calories a day. One pound of body fat equals about 3,500 calories; 3,500 calories
divided by 7 days = 500 calories/day.
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The nurse caring for a client for several days has assessed that he has been eating poorly
during his hospitalization.
Which nursing measure should the nurse implement to assist the client in improving his
nutritional intake?
Encourage his daughter to prepare food at home and bring it to the client.
B)
Serve large meals and encourage the client to eat as much as possible.
C)
Provide distractions while the client is fed so that he will eat more.
D)
Provide bland meals.
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A)
Ans: A
Feedback:
The nurse should solicit food preferences and encourage favorite foods from home,
when possible. Be sure the foods look attractive and the eating area is free of odors,
clutter, and distractions during mealtime. Provide small, frequent meals to avoid
overwhelming the client with large amounts of food.
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A)
“You’ll need to eat more calories and to make sure you eat a balanced diet high in nutrients.”
B)
“Try to eat your normal number of calories, but aim to eat a diet that’s higher in fruits and
vegetables.”
C)
“The more food energy you consume, the greater the chances that you will have a healthy
pregnancy.”
D)
“Maintain your regular calorie intake, but take some supplements and emphasize organic
foods.”
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5.
Which of the following nutritional guidelines should a nurse provide to a client who is
entering the second trimester of
her pregnancy?
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Ans: A
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Nutrient needs during pregnancy increase to support growth and maintain maternal
homeostasis, particularly during the second and third trimesters. During the last two
trimesters, women of normal weight need approximately 300 extra calories per day.
Key nutrient needs include protein, calories, iron, folic acid, calcium, and iodine. It
would be inaccurate to encourage the client to maximize calorie intake.
A)
Confirm that the strip and the meter share the same code.
B)
Massage the client’s finger toward the selected puncture site.
C)
Cleanse the client’s finger with alcohol.
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6.
The nurse is testing the blood glucose levels of a client with a history of diabetes.
The nurse has performed hand hygiene, checked the order, informed the client and
turned on the monitor. After removing a test strip from the vial, the
nurse should do which of the following?
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D)
Pierce the client’s skin with the lancet.
Ans: A
Feedback:
It is important to confirm that the code on the strip and the meter match. This should
precede massaging and cleansing the client’s finger or piercing his/her skin.
A)
“What a good idea. Go ahead. That will jump start your weight loss!”
B)
“Many people find that to be an ideal way to lose weight quickly and easily.”
C)
“That will increase your metabolic rate and help you lose weight.”
D)
“That will decrease your metabolic rate and make weight loss more difficult.”
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7.
A client is discussing weight loss with a nurse. The patient says, “I will not eat for two weeks,
then I will lose at least 10
pounds.” What should the nurse tell the client?
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Ans: D
Most nutritionists agree that fasting or following a very low-calorie diet defeats a
weight-loss plan because the body interprets this eating pattern as starvation, and
compensates by slowing down the basal metabolic rate, making it even more difficult
to lose weight.
8.
Which client will have an increased metabolic rate and require nutritional interventions?
A)
A healthy young adult who works in an office
B)
A retired person living in a temperate climate
C)
A person with a serious infection and fever
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D)
An older, sedentary adult with painful joints
Ans: C
Feedback:
om
Factors that increase metabolic rate include growth, infections, fever, emotional
tension, extreme environmental temperatures, and elevated levels of some hormones.
Aging, prolonged fasting, and sleep decrease metabolic rate.
A)
100
B)
250
C)
500
D)
1,000
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9.
A nurse is helping a client design a weight-loss diet. To lose one pound of fat (3,500 calories)
per week, how many
calories should be decreased each day?
Feedback:
One pound of body fat equals about 3,500 calories. To gain or lose one pound in a
week, daily calorie intake should be reduced by 500 calories per day (3,500 calories
divided by 7 = 500 calories per day).
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A)
Fever, joint pain, dehydration
B)
Poor wound healing, apathy, edema
C)
Sleep disturbances, anger, increased output
D)
Weight gain, visual deficits, erythema of skin
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10.
A hospitalized client has been NPO with only intravenous fluid intake for a prolonged period.
What assessments might
indicate protein-calorie malnutrition?
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Ans: B
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The stress of illness, surgery, or prolonged periods of time on simple intravenous
therapy without oral intake places hospitalized clients at risk for developing proteincalorie malnutrition. This can result in weakness, poor wound healing, mental apathy,
and edema.
How often would a nurse recommend a client eat or drink a source of vitamin C?
A)
Once a week
B)
Once a month
C)
Three times a week
D)
Every day
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11.
Ans: D
Feedback:
Vitamin C, a water-soluble vitamin, is usually not stored in the body. Deficiency
symptoms are apt to develop quickly when intake is inadequate; a daily intake is
recommended.
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A)
Change the plan of care to include forcing fluids.
B)
Ask the client to drink more water during the day.
C)
Post a sign limiting fluids to 1,000 mL every 24 hours.
D)
Continue with care; this is a normal fluid intake.
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12.
While reviewing an adult client’s chart, a nurse notes average daily intake of fluids as 2,000
mL/day. What will the
nurse do based on this information?
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Ans: D
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Water intake averages 2,000 to 2,500 mL/day for adults. The nurse would continue
with care, because the client has a normal fluid intake.
A nurse has documented that a client has anorexia. What does this term mean?
A)
Eating more than daily requirements
B)
Lack of appetite
C)
Vitamin C deficiency
D)
Fluid deficit
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13.
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Ans: B
Feedback:
Anorexia is lack of appetite. It may be related to multiple factors, including diseases,
psychosocial causes, impaired ability to chew and taste, or inadequate income.
A)
Solid foods after the first month
B)
No solid foods until age 1 year
C)
Bottle feeding with cow’s milk
D)
Breast-feeding or formula with iron
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14.
A nurse is discussing infant care with a woman who just had a baby girl. What type of
nutrition would the nurse
recommend for the infant?
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Nutritional needs per unit of weight are greater in infants than at any other time in the
life cycle. Breast-feeding or a commercial formula with iron is recommended as the
major source of nutrition for the first 6 to 12 months of life. Cow’s milk is not
recommended for infants under 1 year. Solid foods are usually not introduced until 6
months.
15.
What information do anthropometric measurements provide in adults?
A)
Indirect measure of protein and fat stores
B)
Direct measure of degree of obesity
C)
Indication of degree of growth rate
D)
Reflection of social interaction with others
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Ans: A
Feedback:
Anthropometric measurements are used to determine body dimensions. In children,
they are used to assess growth rate; in adults, they give indirect measurements of
body protein and fat stores.
What independent nursing intervention can be implemented to stimulate appetite?
A)
Administer prescribed medications.
B)
Recommend dietary supplements.
C)
Encourage or provide oral care.
D)
Assess manifestations of malnutrition.
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16.
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Ans: C
There are many methods of stimulating appetite in a client to prevent malnutrition.
One independent nursing intervention that is useful is to encourage or provide oral
care.
17.
A nurse is feeding a client. Which of the following statements would help a person maintain
dignity while being fed?
A)
“I am going to feed you your cereal first, and then your eggs.”
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B)
“I wish I had more time so I could feed you all of your meal.”
C)
“I know you don’t like me to feed you, but you need to eat.”
D)
“What part of your dinner would you like to eat first?”
Ans: D
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The loss of independence that comes with the inability to self-feed can be a severe
blow to a person’s self-esteem. Asking the person his or her preference regarding the
order of items eaten can help maintain dignity while being fed.
A client has been prescribed a clear liquid diet. What food or fluids will be served?
A)
Milk, frozen dessert, egg substitutes
B)
High-calorie, high-protein supplements
C)
Hot cereals, ice cream, chocolate milk
D)
Jell-O, carbonated beverages, apple juice
Ans: D
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Feedback:
Clear liquid diets contain only foods that are clear liquids at room or body
temperature. Included are gelatin, fat-free broth, bouillon, ice pops, clear juices,
carbonated beverages, regular and decaffeinated coffee, and tea. A full liquid diet
includes all fluids and foods that become liquid at room temperature. This would
include ice cream, chocolate milk, and liquid dietary supplements.
19.
What is the route of administration for TPN?
A)
Oral
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B)
Subcutaneous
C)
Intramuscular
D)
Intravenous
Ans: D
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TPN meets the client’s nutritional needs by way of nutrient-filled solutions
administered intravenously through a central line, usually the subclavian or internal
jugular veins.
A)
Unsaturated fats
B)
Trans fats
C)
Saturated fats
D)
Hydrogenated fats
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20.
A nurse is caring for a client with a history of cardiac and vascular disease. Which of the
following fats should the nurse
allow in the client’s diet for his condition?
Ans: A
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Unsaturated fat is a healthier form of fat than saturated fat, because it contains less
hydrogen, and therefore can be included in the client’s diet. Saturated fats are lipids
that contain as much hydrogen as their molecular structure can hold, and are
generally solid. Most saturated fats are found in animal sources, such as the marbled
fat in meat. Saturated fats are responsible for cardiac and vascular diseases. Trans
fats are unsaturated fats that have been hydrogenated, a process in which hydrogen is
added to the fat. Consumption of trans fats, saturated fats, and hydrogenated fats
increases the risk of coronary heart disease.
A)
Emaciation
B)
Cachexia
C)
Anorexia
D)
Nausea
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21.
A client visits a health care facility with complaints of loss of appetite following a prolonged
illness. How should the
nurse document the client’s condition?
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Ans: C
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The nurse should document the loss of appetite following prolonged illness as
anorexia. Emaciation is excessive leanness. Cachexia is the general wasting away of
body tissue. Nausea usually precedes vomiting and is associated with gastrointestinal
sensations.
22.
A nurse is caring for a client with excessive abdominal fat. Which of the following is a risk
associated with excessive
abdominal fat about which the nurse should inform the client?
A)
Emaciation
B)
Cachexia
C)
Cardiovascular disease
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D)
Anorexia
Ans: C
Feedback:
Excess abdominal fat may lead to cardiovascular disease, hypertension, and diabetes.
Anorexia is the loss of appetite. Emaciation is characterized by excessive leanness.
Cachexia is the general wasting away of body tissue.
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23.
A nurse is caring for a young adult female client who has a folic acid defiency. When teaching
the client about this
condition, the nurse would include a discussion about the client’s increased risk for which of
the following?
Neural tube deficits in the fetus
B)
Inadequate absorption of calcium and phosphorus
C)
Hemolysis of red blood cells
D)
Impaired neuromuscular functioning
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A)
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Folic acid deficiency in pregnant women can lead to neural tube deficits like spina
bifida in the fetus. Because fetal neural development begins so early in pregnancy,
women in their childbearing years must have adequate folic acid intake. Deficiency
in vitamin D intake leads to inadequate absorption of calcium and phosphorus, and a
deficiency of
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mineralization in bones and teeth. Increased hemolysis of red blood cells, poor
reflexes, impaired neuromuscular functioning, and anemias are signs of vitamin E
deficiency, not folic acid deficiency.
A)
Eliminate high-fiber foods
B)
Eat foods high in folic acid
C)
Consume saturated fats
D)
Consume milk products in the last trimester
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24.
To promote health of the fetus, the nurse should instruct the woman in the first trimester of
pregnancy to do which of the
following?
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Folic acid deficiency in pregnant women can lead to neural tube deficits in the fetus.
Women during pregnancy may experience constipation. Increased fiber intake is
recommended. Saturated fats are to be eaten only in moderation. Milk products are
important during the entire pregnancy.
25.
A nurse researching a diet for a client with diabetes includes foods that supply energy to the
body. Which of the
following are classes of nutrients that supply this energy? Select all that apply.
A)
Vitamins
B)
Proteins
C)
Fats
D)
Minerals
E)
Carbohydrates
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Ans: B, C, E
Feedback:
Of the six classes of nutrients, three supply energy (carbohydrates, proteins, lipids
[fats]) and three are needed to regulate body processes (vitamins, minerals, water).
Which of the following factors increase BMR? Select all that apply.
A)
Growth
B)
Infections
C)
Fever
D)
Emotional tension
E)
Aging
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26.
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Ans: A, B, C, D
Factors that increase BMR include growth, infections, fever, emotional tension,
extreme environmental temperatures, and elevated levels of certain hormones,
especially epinephrine and thyroid hormones. Aging, prolonged fasting, and sleep all
decrease BMR.
27.
Which of the following are signs and symptoms of poor nutritional status?
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Flaky facial skin, facial edema, pale skin color
B)
Tongue is a deep red in color with surface papillae present.
C)
Firm, pink nailbeds
D)
Firm hair that is resistant to plucking
Ans:
A
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Healthy skin is uniform in color and not swollen.
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Feedback:
Which of the following laboratory results indicates the presence of malnutrition?
A)
Serum albumin 2.8 g/dL
B)
Hemoglobin (Hgb) 11.3 g/dL
C)
Creatinine 1.9 mg/dL
D)
Hematocrit (Hct) 56%
Ans:
A
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28.
Feedback:
Increased Hct indicates dehydration.
29.
A nutritionist helps to plan a diet for a client with diabetes. Which of the following foods is a
carbohydrate that should
be included to help improve glucose tolerance?
A)
Milk
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B)
Eggs
C)
Oatmeal
D)
Nuts
Ans: C
Feedback:
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Oatmeal is a water-soluble carbohydrate that helps improve glucose tolerance in
diabetics. Milk, eggs, and nuts are proteins.
A)
Underweight
B)
Normal
C)
Overweight
D)
Obesity Class I
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30.
A nurse calculates the BMI of a client during a general survey as 26. Under which of the
following categories would this
client fall?
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BMI values are: Underweight <18.5; normal 18.5 to 24.9; overweight 25.0 to
29.9; obesity class I 30.0 to 34.9; obesity class II 35.0 to 39.9; and extreme obesity
40.0+.
A)
Test results of levels of unsaturated fats
B)
Test results for dyslipidemia
C)
Test results of levels of balanced proteins
D)
Test results of levels of calories in each food intake
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31.
A nurse is caring for a client with complaints of chest pain. Which of the following test results
would indicate whether
the client is at risk for cardiac disease?
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Ans: B
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Health care providers test for dyslipidemia to assess clients’ risks for cardiovascular
disease. Measuring levels of protein, calories, or unsaturated fats will not help to
assess if a client is at risk for cardiac and vascular disease.
32.
For which of the following clients should the nurse anticipate the need for a pureed diet?
A)
A man whose stroke has resulted in difficulty swallowing
B)
A woman who has required gallbladder surgery
C)
A man with dementia who is unable to follow instructions
D)
An obese woman after bariatric surgery
Ans: A
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Pureed diets are indicated for clients who have significant problems chewing and/or
swallowing. Surgery and confusion are not indications for this change in the texture
and consistency of food.
A)
25.1
B)
18.5
C)
20.3
D)
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33.
A nurse performing a nutritional assessment determines that the BMI of a 5’11” (1.8 meters)
male client who weighs 81
kilograms is which of the following?
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Ans: A
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The formula for calculating BMI is (body weight in kilograms) divided by (body
height in meters squared). (weight in kg) (height in meters) * (height in meters)
34.
Most nutritionists recommend increasing fiber in the diet. In addition to other benefits, how
does fiber affect
cholesterol?
A)
Increases fecal excretion of cholesterol
B)
Decreases fecal excretion of cholesterol
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C)
Facilitates intake and use of trans fat
D)
Raises blood cholesterol levels
Ans: A
Feedback:
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To help lower serum cholesterol levels, researchers recommend limiting cholesterol
intake, eating less total fat, eating more unsaturated fat, and increasing fiber intake.
Fiber increases fecal excretion of cholesterol.
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The nurse prepares to administer an intermittent feeding to a client who has a
nasogastric feeding tube. Arrange the following steps in the correct order
Verify correct tube placement.
2.
Position client with head of bed elevated 30 to 45° degrees
3.
Aspirate all gastric contents.
4.
Flush tube with 30 mL water.
5.
Verify that residual volume is less than 400 mL.
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1.
6. Administer feeding.
A)
1, 2, 3, 4, 5, 6
B)
2, 1, 3, 5, 4, 6
C)
2, 3, 1, 4, 6, 5
D)
1, 3, 2, 4, 5, 6
E)
1, 4, 2, 3, 5, 6
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35.
Ans: B
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The correct order for administering an intermittent feed to a client who has a
nasogastric feeding tube is (1) Position client with head of bed elevated 30 to 45°
degrees; (2) Verify correct tube placement; (3) Aspirate all gastric contents;
(4) Verify that residual volume is less than 400 mL; (5) Flush tube with 30 mL water; and (6)
Administer feeding.
Chapter 38, Urinary Elimination
A)
the child can recognize bladder fullness.
B)
the child can hold the urine for four to five hours.
C)
The child cannot control urination until seated on the toilet.
D)
The child ignores the desire to void.
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1.
During a visit to the pediatrician’s office, a parent inquires about toilet training her daughter
age 2 years. The nurse
informs the mother that one factor in determining toilet-training readiness is when …
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Ans: A
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Toilet training usually begins around ages 2 or 3 years. Toilet training should not
begin until the child is able to hold urine for two hours, recognize the feeling of
bladder fullness, communicate the need to void, and control urination until seated on
the toilet.
A)
Suprapubic catheter
B)
Indwelling urethral catheter
C)
Intermittent urethral catheter
D)
Straight catheter
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2.
A client with urine retention related to a complete prostatic obstruction requires a urinary
catheter to drain the bladder.
Which type of catheter is most appropriate for a client that has an obstructed urethra?
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Ans: A
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A suprapubic catheter is used for long-term continuous drainage and is inserted
through a small incision above the pubic area. Suprapubic bladder drainage diverts
urine from the urethra when injury, stricture, prostatic obstruction, or abdominal
surgery has compromised the flow of urine through the urethra.
3.
A patient has developed edema in her lower legs and feet, prompting her physician to
prescribe furosemide (Lasix), a
diuretic medication. After the client has begun this new medication, what should the nurse
anticipate?
A)
Increased output of dilute urine
B)
Increased urine concentration
C)
A risk of urinary tract infections
D)
Transient incontinence and increased urine production
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Ans: A
Feedback:
Diuretics result in moderate to severe increases in the production of dilute urine.
Concentration will decrease, not increase, and there is no accompanying risk of
urinary tract infections. For some clients, this sudden increase in urine output may
precipitate transient incontinence, but this remains an abnormal finding.
A)
Has different innervation
B)
No connection with bladder
C)
Shorter in length
D)
Longer in length
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4.
A nurse is preparing to catheterize a female client. What will the nurse consider when
comparing the anatomy of the
female urethra with that of the male urethra?
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Ans: C
The anatomy of the urethra differs in males and females. The male urethra is about
51/2 to 61/4 inches (13.7 to 16.2 cm) long. The female urethra is about 11/2 to 21/2
inches (3.7 to 6.2 cm) long. This difference is important in terms of catheterization
and risk for infection.
5.
Which of the following describes the term micturition?
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A)
Emptying the bladder
B)
Catheterizing the bladder
C)
Collecting a urine specimen
D)
Experiencing total incontinence
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The process of emptying the bladder is known as urination, micturition, or voiding.
A)
The child should be able to hold urine for four hours.
B)
The child should be between 18 and 24 months old.
C)
The child should be able to communicate the need to void.
D)
The child does not need the desire to gain control of voiding.
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6.
A nurse working in a community pediatric clinic explains the process of toilet training to
mothers of toddlers. Which is a
recommended guideline for initiating this training?
Ans: C
Feedback:
Voluntary control of the urethral sphincters occurs between 18 and 24 months of age.
However, many other factors are required to achieve conscious control of bladder
function, and toilet training usually begins at about 2 to 3 years of age. Toilet training
should not begin until the child is able to hold urine for two hours, recognize the
feeling of bladder fullness, communicate the need to void, and control urination until
seated on the toilet. The child’s desire to gain control is also important.
A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging
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7.
should the nurse consider
when performing a urinary assessment?
A)
The diminished ability of the kidneys to concentrate urine may result in urinary tract infection.
B)
Increased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting
in frequency.
Neuromuscular problems may result in the client finding urinary control too much trouble,
resulting in incontinence.
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C)
Decreased bladder contractility may lead to urine retention and stasis, which increase the
likelihood of urinary tract
infection.
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Ans: C
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Decreased bladder contractility may lead to urine retention and stasis, which increase
the likelihood of urinary tract infection. The diminished ability of the kidneys to
concentrate urine may result in nocturia (urination during the night). Decreased
bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in
increased frequency of urination. Neuromuscular problems, degenerative joint
problems, alterations in thought processes, and weakness may interfere with
voluntary control and the ability to reach a toilet in time. Individuals who view
themselves as old, powerless, and neglected may cease to value voluntary control
over urination, and simply find toileting too much bother no matter what the setting.
Incontinence may be the result.
8.
A nurse is assessing the urine output of a client with Parkinson’s disease who is on levodopa.
Which of the following is
a common finding for a client on this medication?
A)
The urine may be brown or black.
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B)
The urine may be blood-tinged.
C)
The urine may be green or blue-green.
D)
The urine may be orange or orange-red.
Ans: A
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Levodopa (l-dopa), an antiparkinson drug, and injectable iron compounds can lead
to brown or black urine. Anticoagulants may cause hematuria (blood in the urine),
leading to a pink or red color. Diuretics can lighten the color of urine to pale yellow.
Phenazopyridine (Pyridium), a urinary tract analgesic, can cause orange or orangered urine.
A client tells the nurse, “Every time I sneeze, I wet my pants.” What is this type of involuntary
escape of urine called?
A)
Urinary incontinence
B)
Urinary incompetence
C)
Normal micturition
D)
Uncontrolled voiding
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Ans: A
Feedback:
The process of emptying the bladder is termed micturition, voiding, or urination.
Sometimes increased abdominal pressure, such as occurs when sneezing or coughing,
forces an involuntary escape of urine, especially in women because the urethra is
shorter. Any involuntary loss of urine that causes such a problem is referred to as
urinary incontinence.
During a health history interview, a male client tells the nurse that he does not feel that he
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completely empties his
bladder when he voids. He has been diagnosed with an enlarged prostate. What is the name of
this symptom?
A)
Urinary incontinence
B)
Urinary retention
C)
Involuntary voiding
D)
Urinary frequency
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Ans: B
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Urinary retention occurs when urine is produced normally but is not excreted
completely from the bladder. Factors associated with urinary retention include
medications, an enlarged prostate, or vaginal prolapse. Incontinence is involuntary
loss of urine from the bladder. Retention is an accumulation of urine in the bladder.
Frequency is voiding more often than usual.
A nurse is assessing the urine on a newborn’s diaper. What would be a normal assessment
finding?
A)
Scanty to no urine
B)
Highly concentrated urine
C)
Light in color and odorless
D)
Dark in color and
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odorous Ans: C
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Feedback:
Infants are born with little ability to concentrate urine. An infant’s urine is usually
very light in color and without odor until about 6 weeks of age, when the nephrons
are able to control reabsorption of fluids and effectively concentrate urine. Infants do
not normally have scanty, highly concentrated, or dark and odorous urine.
A)
Diminished kidney ability to concentrate urine
B)
Increased bladder muscle tone causing urinary frequency
C)
Increased bladder contractility causing urinary stasis
D)
Decreased intake of fluids during daytime hours
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12.
An older woman who is a resident of a long-term care facility has to get up and void several
times during the night. This
can be the result of what physiologic change with normal aging?
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Physiologic changes that accompany normal aging may affect urination in older
adults. These changes include the diminished ability to concentrate urine that may
result in nocturia (voiding during the night). Aging does not result in increased
bladder muscle tone or increased bladder contractility. A decrease in fluid intake
would not result in nocturia.
13.
After surgery, a postoperative client has not voided for eight hours. Where would the nurse
assess the bladder for
distention?
A)
Between the symphysis pubis and the umbilicus
B)
Over the costovertebral region of the flank
C)
In the left lower quadrant of the abdomen
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D)
Between ribs 11 and 12 and the umbilicus
Ans: A
Feedback:
When the bladder is distended with urine, it rises above the symphysis pubis and may
reach to just below the umbilicus. The other choices are anatomically incorrect for
assessing a distended bladder.
A)
Compare the amount of output with intake.
B)
Use a clean measuring cup for each voiding.
C)
Tell the client to wash the urethra before voiding.
D)
Wear gloves when handling a client’s urine.
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14.
A nurse is delegating the collection of urinary output to an assistant. What should the nurse
tell the assistant to do while
measuring the urine?
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Ans: D
Feedback:
Gloves are required when handling urine to prevent exposure to pathogenic
microorganisms or blood that may be present in the urine. In addition, goggles are
also worn if there is a concern of urine splashing.
15.
A nurse has instructed a client at the clinic about collecting a specimen for a routine urinalysis.
The client makes the
following statements. Which one indicates a need for more teaching?
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A)
“I need to tell you that I am having my menstrual period.”
B)
“I will void into the specimen bottle you gave me.”
C)
“I will keep the toilet paper in the specimen.”
D)
“I will be sure that no stool is included in my urine.”
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Ans: C
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Urine for a routine urinalysis does not have to be sterile. Ask the client to void into a
clean receptacle and avoid contamination with stool. Note on the request form if a
woman is having her menstrual period. Instruct clients not to put toilet paper into the
urine because this makes analysis more difficult.
A)
Pour urine from the collecting bag.
B)
Remove the catheter and ask the client to void.
C)
Aspirate urine from the collecting bag.
D)
Aspirate urine from the collection port.
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16.
A student is collecting a sterile urine specimen from an indwelling catheter. How will the
student correctly obtain the
specimen?
Ans: D
Feedback:
When it is necessary to collect a urine specimen from a client with an indwelling
catheter, it should always be obtained from the catheter itself using the special
collection port.
A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing
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the nurse will ask the
client to do at the beginning of the specimen collection?
A)
Void and discard the urine.
B)
Begin the collection at a specific time.
C)
Add the first voiding to the specimen.
D)
Keep the urine warm during collection.
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Ans: A
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The collection is initiated at a specific time, but the client is asked to void at that time
and discard the urine from the first voiding. In most instances, a preservative is added
to the collection bottle, or the collected urine is kept cold through refrigeration or
putting it on ice.
A)
Social Isolation
B)
Impaired Adjustment
C)
Defensive Coping
D)
Impaired Memory
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18.
An older adult woman has constant dribbling of urine. The associated discomfort, odor, and
embarrassment may support
which of the following nursing diagnoses?
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Ans: A
Feedback:
Urinary incontinence is a special problem for older adults who may have decreasing
control over micturition, or find it more difficult to reach the toilet in time. The
discomfort, odor, and embarrassment of urine-soaked clothing can greatly diminish a
person’s self-concept, causing him or her to feel like a social outcast.
A)
Assist him to a standing position.
B)
Tell him he has to void to be discharged.
C)
Pour cold water over his genitalia.
D)
Ask his wife to assist with the urinal.
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19.
A male client who has had outpatient surgery is unable to void while lying supine. What can
the nurse do to facilitate his
voiding?
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Ans: A
Helping clients assume their usual voiding positions may be all that is necessary to
resolve an inability to void. If male clients cannot void lying down, encourage them
to void while standing at the bedside unless this is contraindicated.
20.
A nurse is educating a client on the amount of water to drink each day. What is the
recommended daily fluid intake for
adults?
A)
1 to 2 (4-oz) glasses per day
B)
5 to 6 (6-oz) glasses per day
C)
8 to 10 (8-oz) glasses per day
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D)
16 to 20 (12-oz) glasses per day
Ans: C
Feedback:
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Adults with no disease-related fluid restrictions should drink 2,000 to 2,400 mL (8 to
10 8-oz glasses) of fluid daily. Monitor fluid intake for those that are high in caffeine,
sodium, and sugar.
A nurse is carrying out an order to remove an indwelling catheter. What is the first step of this
skill?
A)
Deflate the balloon by aspirating the fluid.
B)
Ask the client to take several deep breaths.
C)
Tell the client burning may initially occur.
D)
Wash hands and put on gloves.
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21.
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Feedback:
Although all the steps listed are correct, the first step of any skill involving body fluids is to
wash hands and don gloves.
22.
A nurse has catheterized a client to obtain urine for measuring postvoid residual (PVR)
amount. The nurse obtains 40
mL of urine. What should the nurse do next?
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A)
Report this abnormal finding to the physician.
B)
Perform another catheterization to verify the amount.
C)
Document this normal finding for postvoid residual.
D)
Palpate the abdomen for a distended bladder.
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Ans: C
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A postvoid residual (PVR) urine measures the amount of urine remaining in the
bladder after voiding. It can be measured by catheterization or a bladder scan. A
PVR of less than 50 mL indicates adequate bladder emptying. The nurse would
document this normal finding for PVR.
A nurse is inserting an indwelling urethral catheter. What type of supplies will the nurse need
for this procedure?
A)
A clean catheter and rubber gloves
B)
A sterile catheterization kit or tray
C)
Solutions to sterilize the urethra
D)
Solutions to sterilize the vagina
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23.
Ans: B
Feedback:
The bladder is a sterile environment. The urethra and vagina cannot be sterilized. The
equipment used for catheterization is usually prepackaged in a sterile disposable kit
or tray.
A client has been taught how to do Kegel exercises. What statement by the client indicates a
need for further
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24.
information?
A)
“I understand these will help me control stress incontinence.”
B)
“I know this is also called pelvic floor muscle training.”
C)
“I will do these 30 to 80 times a day for two months.”
D)
“I will contract the muscles in my abdomen and thighs.”
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Ans: D
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Kegel exercises, or pelvic floor muscle training, are used to tone and strengthen the
muscles that support the bladder. They can improve voluntary control of urination
and thus improve or eliminate stress incontinence. The muscles to contract are the
same ones used to stop urination midstream or control defecation. The client should
not contract the muscles of the abdomen, inner thigh, or buttocks while doing Kegel
exercises.
A)
Public embarrassment
B)
Skin breakdown and UTI
C)
Inability to control urine
D)
Odor and leakage
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25.
A man with urinary incontinence tells the nurse he wears adult diapers for protection. What
risks should the nurse
discuss with this client?
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Ans: B
Feedback:
Clients frequently turn to absorbent products for protection when they are
incontinent of urine and if they have not had this condition properly diagnosed and
treated. When used improperly, such products may cause skin breakdown and place
the client at risk for a UTI.
A)
“I will take showers rather than baths.”
B)
“I will wear underpants with cotton crotches.”
C)
“I will tell my parents if I have burning or pain.”
D)
“I will wipe back to front after going to the toilet.”
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26.
A school nurse is educating a class of middle-school girls on how to promote urinary system
health. Which of the
following statements by one of the girls indicates a need for more information?
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Ans: D
Teaching about measures to promote urinary system health is a major nursing
responsibility. Measures include drying the perineal area after urination or defecation
from the front to the back (or from urethra to rectum).
27.
A client is taking diuretics. What should the nurse teach the client about his urine?
A)
Urinary output will be decreased.
B)
Urinary output will be increased.
C)
Urine will be a pale yellow color.
D)
Urine may be brown or black.
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Ans: C
Feedback:
Certain drugs cause the urine to change color. Diuretics can lighten the color of urine
to pale yellow. The nurse should inform the client about this side effect of the
medication.
A)
“We do these procedures every day, so you don’t need to worry.”
B)
“I have had this done to me, and it only hurt for a little while.”
C)
“Why are you so worried? Do you think you have a tumor?”
D)
“Let me explain to you what they do during this procedure.”
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28.
A nurse is preparing a client for an invasive diagnostic procedure of the urinary system. What
statement by the nurse
would help reduce the client’s anxiety?
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Ans: D
Various diagnostic procedures, typically performed in a hospital operating room or
outpatient facility, are used to study the urinary system. Nurses are responsible for
preparing the client and giving aftercare. Explaining the procedure helps reduce the
client’s anxiety.
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Anuria
B)
Oliguria
C)
Polyuria
D)
Dysuria
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29.
A nurse is caring for a client who is being treated for bladder infection. The client complains
to the nurse that he has
been having difficulty voiding and feels uncomfortable. How should the nurse document the
client’s condition?
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Ans: D
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The nurse could document the client’s condition as dysuria, which is difficulty or
discomfort when voiding. Dysuria is a common symptom of trauma to the urethra or
bladder infection. Anuria means absence of urine or a volume of 100 mL or less in 24
hours. Oliguria indicates inadequate elimination of urine. Polyuria is the term used to
indicate greater than normal urinary volume, and may accompany minor dietary
variations.
A)
Condom catheter
B)
Urinary bag
C)
Straight catheter
D)
Retention catheter
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30.
A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility.
If a catheter is required
temporarily, which type of catheter should the nurse use?
Ans: C
Feedback:
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The nurse should use a straight catheter to collect a sterile urine specimen from the
client. A straight catheter is a urine drainage tube inserted but not left in place. It
drains urine temporarily or provides a sterile urine specimen. Condom catheters are
helpful for clients with urinary incontinence receiving care at home, because they are
easy to apply. A urinary bag is more often used to collect urine specimens from
infants. A retention catheter, also called an indwelling catheter, is left in place for a
period of time.
A)
“I should take frequent bubble baths.”
B)
“I need to void after sexual intercourse.”
C)
“I should wipe from back to front after going to the bathroom.”
D)
“I need to wear pants that are snug fitting.”
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31.
A client with a urinary tract infection is to be discharged from the health care facility.
After teaching the client about measures to prevent urinary tract infections, the nurse
determines that the education was successful when the client
states which of the following?
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Ans: B
The client’s statement about voiding after sexual intercourse to prevent urinary tract
infection is accurate. Taking frequent bubble baths, wiping the perineum from back
to front, and wearing snug fitting pants increases the risk of urinary tract infection.
The client should avoid taking frequent bubble baths, using harsh soaps, and wearing
tight-fitting pants because they can irritate the urethra. The client also should always
wipe from front to back after urinary or fecal elimination.
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A)
Polyuria
B)
Dysuria
C)
Nocturia
D)
Hematuria
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32.
A client is admitted to the health care facility with complaints of pain on urination that is
secondary to a urinary tract
infection (UTI). The nurse documents this finding as which of the following?
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Dysuria means painful voiding. Pain is often associated with UTIs and is felt as a
burning sensation duringurination. Polyuria is the formation and excretion of
excessive amounts of urine in the absence of a concurrent increase in fluid intake.
Voiding during normal sleeping hours is called nocturia. Hematuria refers to blood
in the urine.
What is the micturition reflex?
A)
The process of filtration beginning with the glomerulus
B)
The act of bladder contraction and perceived need to void
C)
The reabsorption of the substances the body wants to retain
D)
The secretion of electrolytes that are harmful to the body
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33.
Ans: B
Feedback:
Several words are used to describe the process of excreting urine from the body,
including urination, voiding, and micturition.
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A)
Supine
B)
Sims’
C)
High Fowler’s
D)
Dorsal recumbent
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34.
A nurse is using a bladder scanner to assess the bladder volume of a client with urinary
frequency. In which of the
following positions would the nurse place the client?
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Ans: A
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Portable bladder ultrasound devices are accurate, reliable, and noninvasive devices
used to assess bladder volume. Results are most accurate when the client is in the
supine position during the scanning.
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35.
The home health nurse is caring for an older adult woman living alone at home who is
incontinent of urine and changes
her adult diaper daily. Which of the following nursing diagnoses is the most appropriate for
this client?
A)
Risk for activity intolerance
B)
Risk for impaired skin integrity
C)
Risk for infection
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D)
Risk for falls
Ans: B
Feedback:
A client who is incontinent, utilizes adult diapers, and only changes them daily is at
Risk for Impaired Skin Integrity in the genital and perineal area.
Chapter 39, Bowel Elimination
A)
Constipation
B)
Diarrhea
C)
Deficient fluid volume
D)
Excessive fluid volume
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1.
The nursing instructor informs a student nurse that a client she is caring for has a chronic
neurologic condition that
decreases the client’s peristalsis. What nursing diagnosis is the most likely risk for this client?
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Ans: A
Peristalsis is defined as the contractions of the circular and longitudinal muscles of
the intestine. Decreased peristalsis will result in constipation because the movement
of the fecal mass will occur at a slower rate and more fluid will be absorbed in the
colon.
2.
During defecation, the client experiences decreased cardiac output related to the Valsalva
maneuver. After the Valsalva
maneuver, the nurse assesses the client’s vital signs and expects to observe which of the
following?
A)
An increase in the client’s blood pressure
B)
A decrease in the client’s blood pressure
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C)
An increase in the client’s respiratory rate
D)
A decrease in the client’s respiratory rate
Ans: A
Feedback:
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When an individual bears down to defecate, the increased pressures in the abdominal
and thoracic cavities result in a decreased blood flow and a temporary decrease in
cardiac output. Once the bearing down ceases, the pressure is lessened, and a larger
than normal amount of blood returns to the heart; this act elevates the client’s blood
pressure.
A)
Golden yellow and loose
B)
Dark brown and firm
C)
Yellow-brown and pasty
D)
Green and
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3.
While caring for an infant who is breast-fed, the nurse assesses the characteristics of the
stools. What stool
characteristics are expected in breast-fed infants?
mucusy Ans: A
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Feedback:
Breast-fed infants have more frequent stools, and the stools are yellow to golden,
loose, and usually have little odor. With formula or cow’s milk feedings, infants’
stools vary from yellow to brown and are pasty in consistency.
A)
Hard, formed
B)
Black, tarry
C)
Soft, watery
D)
Dry, odorous
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4.
Which type of stool would the nurse assess in a client with an illness that causes the stool to
pass through the large
intestine quickly?
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Ans: C
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About 800 to 1,000 mL of liquid is absorbed daily by the large intestine. When
absorption does not occur properly, such as when the waste products pass through the
large intestine rapidly, the stool is soft and watery.
5.
A nurse is assessing the stools of a breastfed baby. What is the appearance of normal stools for
this baby?
A)
Yellow, loose, odorless
B)
Brown, paste-like, some odor
C)
Brown, formed, strong odor
D)
Black, semiformed, no odor
Ans: A
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Feedback:
Breast-fed babies have more frequent stools, and the stools are yellow to golden
and loose, usually with little odor. Breast-fed babies can normally have 2 to 10
stools per day.
A)
“When he does this, scold him and he will quit.”
B)
“I don’t understand why this child is losing control.”
C)
“This is normal when a child this age is hospitalized.”
D)
“I will have to call the doctor and report this behavior.”
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6.
A hospitalized toddler, previously bowel trained, has been having incontinent stools. What
would the nurse tell the
parents about this behavior?
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Discourage the use of punishment or shame for elimination accidents. Toddlers who
are toilet trained often regress and experience soiling when hospitalized, and scolding
or acting disgusted only reinforces the behavior.
7.
A client is having difficulty having a bowel movement on the bedpan. What is the physiologic
reason for this problem?
A)
It is painful to sit on a bedpan.
B)
The position does not facilitate downward pressure.
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C)
The position encourages the Valsalva maneuver.
D)
The cause is unknown and requires further study.
Ans: B
Feedback:
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Most people assume the squatting or slightly forward-sitting position with the thighs
flexed to defecate. These positions result in increased pressure on the abdomen and
downward pressure on the rectum to facilitate defecation. Obtaining the same results
when seated on a bedpan is difficult.
A)
Decrease high-fiber foods
B)
Decrease amount of fluids
C)
Omit fruits if eating vegetables
D)
Nothing; this is a good diet
Ans: D
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8.
The following foods are a part of a client’s daily diet: high-fiber cereals, fruits, vegetables,
2,500 mL of fluids. What
would the nurse tell the client to change?
Feedback:
A high-fiber diet and a daily fluid intake of 2,500 to 3,000 mL of fluids facilitate bowel
elimination. Intake of the foods described makes the feces more bulky, so they move
through the intestine more quickly. The stool is softer and the time to absorb toxins is
decreased (toxins are believed to have a role in the development of colon cancer).
9.
A young woman comes to the emergency department with severe abdominal cramping and
frequent bloody stools. Food
poisoning is suspected. What diagnostic test would be used to confirm this diagnosis?
A)
Routine urinalysis
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B)
Chest x-ray
C)
Stool sample
D)
Sputum sample
Ans: C
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Feedback:
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.c
Outbreaks of food poisoning can result in severe gastrointestinal symptoms. Severe
abdominal cramping followed by watery or bloody diarrhea may signal a microbial
infection, which can be confirmed by a stool sample.
A)
It is the most painful assessment method
B)
It is the most embarrassing assessment method
C)
To allow time for the examiner’s hands to warm
D)
It disturbs normal peristalsis and bowel motility
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10.
A nurse is conducting an abdominal assessment. What is the rationale for palpating the
abdomen last in the sequence
when conducting an abdominal assessment?
Ans: D
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The sequence for abdominal assessment is inspection, auscultation, percussion, and
palpation. Inspection and auscultation are performed before palpation because
palpation may disturb normal peristalsis and bowel motility.
What are two essential techniques when collecting a stool specimen?
A)
Hand hygiene and wearing gloves
B)
Following policies and selecting containers
C)
Wearing goggles and an isolation gown
D)
Using a no-touch method and toilet paper
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11.
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Ans: A
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Use of medical aseptic techniques when collecting a stool specimen is imperative.
Hand hygiene, before and after wearing rubber gloves, is essential.
What is occult blood?
A)
Bright red visible blood
B)
Dark black visible blood
C)
Blood that contains mucus
D)
Blood that cannot be seen
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12.
Ans: D
Feedback:
Occult blood in the stool is blood that is hidden in the specimen or cannot be seen on
gross examination. It can be detected with simple screening tests, such as a
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Hematest.
A nurse is scheduling diagnostic studies for client. Which test would be performed first?
A)
Fecal occult blood test
B)
Barium study
C)
Endoscopic exam
D)
Upper gastrointestinal series
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13.
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Ans: A
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Nurses are commonly involved in scheduling diagnostic studies when a client is to
undergo multiple studies. They should follow a logical sequence when more than
one test is required for accurate diagnosis; that is, fecal occult blood tests to detect
gastrointestinal bleeding; barium studies to visualize gastrointestinal structures and
reveal any inflammation, ulcers, tumors, strictures, or other lesions; and endoscopic
examinations to visualize an abnormality, locate a source of bleeding, and if
necessary, provide biopsy tissue samples.
A)
Imbalanced Nutrition: Less than Body Requirements
B)
Deficient Fluid Volume
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14.
A client has had frequent watery stools (diarrhea) for an extended period of time. The client
also has decreased skin
turgor and dark urine. Based on these data, which nursing diagnosis would be appropriate?
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C)
Impaired Tissue Integrity
D)
Impaired Urinary Elimination
Ans: B
Feedback:
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Bowel elimination problems may also affect other areas of human functioning. For
example, excessive diarrhea causes loss of body fluid, with resulting decreased skin
turgor and concentrated urine. Deficient Fluid Volume is an appropriate nursing
diagnosis based on the data.
An infant has had diarrhea for several days. What assessments will the nurse make to identify
risks from the diarrhea?
A)
Heart tones
B)
Lung sounds
C)
Skin turgor
D)
Activity level
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15.
Feedback:
When infants and children become ill, they lose most fluids from their extracellular
compartment, which quickly leads to dehydration. The nurse would assess skin turgor
to identify this problem.
16.
A client tells the nurse that he takes laxatives every day but is still constipated. The nurse’s
response is based on:
A)
Habitual laxative use is the most common cause of chronic constipation.
B)
If laxatives are not effective, the client should begin to use enemas.
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C)
A laxative that works by a different method should be used.
D)
Chronic constipation is nothing to be concerned about.
Ans: A
Feedback:
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Occasional use of laxatives is not harmful for most people, but they should not
become dependent on them. Although many people do take laxatives because they
believe they are constipated, most are unaware that habitual use of laxatives is the
most common cause of chronic constipation.
A)
Stool-softening laxatives, such as Colace
B)
Increasing fluid intake to 3,000 mL/day
C)
Drinking fluids with a high sugar content
D)
Eating fermented products, such as yogurt
Ans: D
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17.
A client who has been on a medication that caused diarrhea is now off the medication. What
could the nurse suggest to
promote the return of normal flora?
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Some medications, such as antibiotics, may destroy normal intestinal flora and cause
diarrhea. To promote the return of normal flora, the nurse can recommend an intake
of fermented dairy products, such as buttermilk or yogurt.
A client is on bedrest, and an enema has been ordered. In what position should the nurse
position the client?
A)
Fowler’s
B)
Sims’
C)
Prone
D)
Sitting
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A reclining position on the left side (Sims’ position) is recommended. The head may
be slightly elevated, but Fowler’s position should be avoided because the solution will
remain in the rectum and expulsion will occur rapidly, resulting in minimal cleansing.
Which is an expected outcome for a client undergoing a bowel training program?
A)
Have a soft, formed stool at regular intervals without a laxative.
B)
Continue to use laxatives, but use one less irritating to the rectum.
C)
Use oil-retention enemas on a regular basis for elimination.
D)
Have a formed stool at least twice a day for two weeks.
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Ans: A
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Clients who have chronic constipation and impaction, and those who are incontinent
of stool, may benefit from a bowel training program. The purpose of this program is
to manipulate factors within the client’s control (such as exercise or fluid intake) to
produce the elimination of a soft, formed stool at regular intervals without a laxative.
A)
“Just give it a few more days and you should be fine.”
B)
“Well, that shouldn’t happen. Let me recommend a good laxative for you.”
C)
“When you increase fiber in your diet, you also need to increase liquids.”
D)
“I will tell the doctor you are having problems; maybe he can help.”
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20.
A client tells the nurse, “I increased my fiber, but I am very constipated.” What further
information does the nurse need
to tell the client?
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Acombination of high-fiber foods, 8 to 10 glasses of water a day, and exercise has
been shown to be as effective as medications in controlling constipation. Caution
the client to avoid increasing fiber intake without drinking enough fluids because
this can lead to a bowel obstruction.
21.
A nurse is documenting the appearance of feces from a client with a permanent ileostomy.
Which of the following
would she document?
A)
“Ileostomy bag half filled with liquid feces.”
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B)
“Ileostomy bag half filled with hard, formed feces.”
C)
“Colostomy bag intact without feces.”
D)
“Colostomy bag filled with flatus and feces.”
Ans: A
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The client with an ileostomy (temporary or permanent) has an opening into the small
intestine. Because feces do not reach the large intestine, water is not absorbed, and
the feces will be liquid.
A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a
normal, healthy stoma?
A)
Pallor
B)
Purple-blue
C)
Irritation and bleeding
D)
Dark red and moist
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22.
Feedback:
The ostomy stoma should be dark pink to red and moist. Abnormal findings include
paleness (possible anemia), purple- blue color (possible ischemia), or bleeding.
23.
A nurse is caring for a client who is postoperative Day 1 for a temporary colostomy. The nurse
assesses no feces in the
collection bag. What should the nurse do next?
A)
Notify the physician immediately.
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B)
Ask another nurse to check her findings.
C)
Nothing; this is normal.
D)
Recheck the bag in two hours.
Ans: C
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Typically, a colostomy does not produce drainage or feces until normal peristalsis
returns after surgery, usually within two to five days.
A)
During the first six to eight weeks after surgery, eat foods high in fiber.
B)
Drink at least two quarts of fluids, preferably water, daily.
C)
Use enteric-coated or sustained-release medications if needed.
D)
Use a mild laxative if needed.
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24.
A nurse is providing discharge instructions for a client with a new colostomy. Which of the
following is a recommended
guideline for long-term ostomy care?
Ans: B
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During the first six to eight weeks after surgery, the nurse should encourage the client
with an ostomy to avoid foods high in fiber (e.g., foods with skins, seeds, and shells)
as well as any other foods that cause diarrhea or excessive flatus. By gradually adding
new foods, the ostomy client can progress to a normal diet. The nurse should urge
clients to drink at least two quarts of fluids, preferably water, daily. The use of liquid,
chewable, or injectable forms rather than long- acting, enteric-coated, or sustainedrelease medications is recommended. Laxatives and enemas are dangerous because
they may cause severe fluid and electrolyte imbalance.
A)
Inserted a lubricated, gloved finger into the rectum.
B)
Obtain a sharp intestinal x-ray.
C)
Insert a lubricated rectal tube into the rectum.
D)
Administer an oil retention enema into the rectum.
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25.
A nurse is assessing a client with constipation and severe rectal pain. Which of the following
actions should the nurse
perform to determine the presence of fecal impaction?
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Ans: A
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The nurse should insert a lubricated, gloved finger into the rectum to determine the
presence of fecal impaction. Fecal impaction occurs when a large, hardened mass of
stool interferes with defecation. Obtaining a sharp intestinal x-ray is not a good idea
because the barium retained in the intestine causes fecal impaction. Insertion of a
rectal tube and administration of an oil retention enema are measures used to remove
hardened stool,
not assess it.
26.
The nurse is assessing a client with abdominal complaints. The nurse performs deep palpation
of the abdomen for which
reason?
A)
Detect abdominal masses
B)
Determine abdominal firmness
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C)
Assess softness of abdominal muscles
D)
Assess degree of abdominal distention
Ans: A
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The purpose of the deep palpation is to detect abdominal masses. Light palpation of
the abdomen helps to determine the firmness or softness of the abdominal muscles
and the degree of abdominal distention.
A)
Avoid giving solid food
B)
Administer a laxative to the client
C)
Monitor for rectal bleeding
D)
Limit oral fluid intake
Ans: C
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27.
A nurse is providing care to a client who has undergone a colonoscopy. Which of the
following would be most
appropriate for the nurse to do after the procedure?
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The nurse should monitor the client for rectal bleeding after a colonoscopy. The nurse
should provide rest and offer food and fluids as allowed. The evening before the
procedure, solid foods are avoided and liquids are encouraged. Laxatives are also
given before the procedure.
A)
Constipation
B)
Perceived constipation
C)
Risk of constipation
D)
Bowel incontinence
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28.
During a home visit, the nurse learns that the client ensures a daily bowel movement
with the help of laxatives. The client feels that deviation from a bowel movement
every day is unhealthy. Which nursing diagnosis would the nurse
most likely identify?
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Ans: B
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The most appropriate nursing diagnosis for the client is perceived constipation,
because the client has made a self- diagnosis of constipation and ensures a daily
bowel movement through the abuse of laxatives. Constipation may be diagnosed in a
client if there is a decrease in the normal frequency of defecation accompanied by a
difficult or incomplete passage of stool (and/or passage of excessively hard, dry
stool). Risk of constipation can be diagnosed if a client exhibits factors that
predispose him or her for developing constipation. Bowel incontinence would be
indicated if the client was experiencing an involuntary passage of stool.
29.
A young woman has just consumed a serving of ice cream pie and develops severe cramping
and diarrhea. The school
nurse suspects the woman is …
A)
Allergic to sugar
B)
Lactose intolerant
C)
Experiencing infectious diarrhea
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D)
Deficient in fiber
Ans: B
Feedback:
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Many people have difficulty digesting lactose (the sugar contained in milk products).
The breakdown of lactose into its component sugars, glucose and galactose, requires
a sufficient quantity of the enzyme lactase in the small intestine. If a person is
lactose-deficient, alterations of bowel elimination, including formation of gas,
abdominal cramping, and diarrhea, can occur after ingestion of milk products.
A)
Increased bowel sounds
B)
Abdominal tenderness
C)
Areas of distention
D)
Muscular resistance
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30.
A nurse assesses the abdomen of a client before and after administering a small-volume
cleansing enema. What
condition would be an expected finding?
Feedback:
The goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds.
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A)
Oil retention enema
B)
Carminative enema
C)
Anthelmintic enema
D)
Nutritive enema
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31.
A physician orders a retention enema for a client to destroy intestinal parasites. Which of the
following enemas would be
indicated for this client?
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Ans: C
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Anthelmintic enemas are administered to destroy intestinal parasites. Oil retention
enemas help to lubricate the stool and intestinal mucosa, making defecation easier.
Carminative enemas help to expel flatus from the rectum and relieve distention.
Nutritive enemas are administered to replenish fluids and nutrition rectally.
A)
Position the client in supine position as dictated by client comfort and condition.
B)
Insert generously lubricated finger gently into the anal canal, pointing away from the
umbilicus.
C)
Gently work the finger around and into the hardened mass to break it up and then remove
pieces of it.
D)
Instruct the client not to bear down while extracting feces to prevent vagal response.
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32.
A nurse is ordered to perform digital removal of stool on a client with stool impaction. Which
of the following is an
appropriate step in this procedure?
Ans: C
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For digital removal of stool: Position the client on the left side (Sims’ position), as
dictated by client comfort and condition. Generously lubricate index finger with
water-soluble lubricant and insert finger gently into anal canal, pointing toward the
umbilicus. Gently work the finger around and into the hardened mass to break it up
and then remove pieces of it. Instruct the client to bear down, if possible, while
extracting feces, which will ease in removal.
A)
The peristomal skin is excoriated or irritated because the appliance is cut too large.
B)
The system has leaks or poor adhesion leading to noticeable odor.
C)
The bag continues to come loose and become inverted.
D)
The stoma is protruding into the bag and may become twisted.
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33.
A nurse assessing a client with an ostomy appliance documents the condition “prolapse” in the
client chart and notifies
the physician. Which of the following statements describes this condition?
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Ans: D
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During prolapse, the stoma is protruding into the bag. The nurse should have the
client rest for 30 minutes and, if stoma is not back to normal size within that time,
notify the physician. If stoma stays prolapsed, it may twist, resulting in impaired
circulation to the stoma.
34.
A nurse is following a physician’s order to irrigate the NG tube of a client. Which of the
following is a recommended
guideline in this procedure?
A)
Assist client to 30- to 45-degree position, unless this is contraindicated.
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B)
Draw up 60 mL of saline solution (or amount indicated in the order or policy) into syringe.
C)
If Salem sump or double-lumen tube is used, make sure that syringe tip is placed in the blue
air vent.
D)
If unable to irrigate the tube, reposition client and attempt irrigation again; inject 20 to 30 mL
of air and aspirate again.
Ans: A
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To irrigate an NG tube, assist the client to 30- to 45-degree position, unless this is
contraindicated. Pour the irrigating solution into the container and draw up 30 mL of
saline solution (or amount indicated in the order or policy) into syringe. If Salem
sump or double-lumen tube is used, make sure that syringe tip is placed in the
drainage port and not in the blue air vent. If unable to irrigate the tube, reposition the
client and attempt irrigation again. Inject 10 to 20 mL of air and aspirate again.
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Then nurse is preparing to apply a fecal incontinence pouch. Arrange the following steps in the
correct order.
Cleanse entire perianal area and pat dry.
2.
Apply skin protectant and allow it to dry.
3.
Separate buttocks and apply the pouch to the anal area.
4.
Attach the pouch to a urinary drainage bag.
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1.
35.
5. Hang the drainage bag below the patient.
A)
2, 3, 4, 5, 1
B)
3, 4, 5, 1, 2
C)
1, 2, 3, 4, 5
D)
5, 4, 3, 2, 1
Ans
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C
Feedback:
A nurse would not be able to determine if the entire intestinal tract is clear
Chapter 40, Oxygenation and Perfusion
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1.
The nurse caring for a client with emphysema has determined that a priority nursing
diagnosis for this client is “Imbalanced Nutrition: Less Than Body Requirements
related to difficulty breathing while eating.” Based upon this
diagnosis, which of the following is an appropriate nursing intervention to include in the
client’s care plan?
Provide six small meals daily.
B)
Provide three large meals daily.
C)
Encourage the client to eat immediately before breathing treatments.
D)
Encourage the client to alternate eating and using a nebulizer during meal time.
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A)
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Ans: A
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Feedback:
The nurse should consider providing six small meals distributed over the course of the
day instead of three large meals. Meals should be eaten one to two hours after
breathing treatments and exercises.
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2.
The nurse is developing a plan of care for a client admitted with pneumonia. The
nurse has determined that apriority nursing diagnosis for this client is “Ineffective
Airway Clearance related to copious and tenacious secretions.” Based
upon this nursing diagnosis, what is an appropriate nursing intervention to include in the
client’s care plan?
Encouraging the client to consume two to three quarts of clear fluids daily
B)
Creating an environment that is likely to reduce anxiety
C)
Positioning the client supine
D)
Encouraging the client to decrease the number of cigarettes smoked daily
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A)
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Ans: A
Clients can help keep their secretions thin by drinking two to three quarts (1.9 L to
2.9 L) of clear fluids daily. Although it is important to create an environment that is
likely to reduce a client’s anxiety, doing so will not assist in promoting airway
clearance. The nurse should not encourage the client to decrease the number of
cigarettes smoked daily, but should encourage the client to stop smoking. Proper
positioning to ease respirations includes placing the client in a high- Fowler’s
position.
3.
A)
While the nurse is providing morning hygiene for a client who has a chest tube, the client
has rolled over quickly and the
chest tube has become disconnected from the drainage unit. How should the nurse first
respond to this event?
Submerge the end of the tube in sterile water.
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B)
Clamp the tube near the end and also near the insertion point.
C)
Place the end of the tube on a sterile surface and seek help promptly.
D)
Clean the end of the tube with an alcohol swab and reconnect it to the drainage unit.
Ans: A
Feedback:
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If a chest tube becomes disconnected from the drainage unit, the nurse should
submerge the end of the tube in a bottle of sterile water, thus preventing a
pneumothorax but still allowing air to escape.
A)
Chemoreceptors
B)
Stretch receptors
C)
Respiratory center
D)
Oxygen center
Ans: C
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4.
A client has had a head injury affecting the brain stem. What is located in the brain stem
that may affect respiratory
function?
Feedback:
The medulla in the brain stem, immediately above the spinal cord, is the respiratory
center. Stretch receptors are located in muscles. Chemoreceptors that affect
respirations are located in the aortic arch and the carotid bodies.
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Which of the following diseases may result in decreased lung compliance?
A)
Emphysema
B)
Appendicitis
C)
Acne
D)
Chronic diarrhea
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Ans: A
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Lung compliance refers to the stretchability of the lungs, or the ease with which lungs
can be inflated. Emphysema, a chronic lung disease, and the normal changes associated
with aging are examples of conditions that result in decreased elasticity of lung tissue,
which in turn decreases lung compliance.
A)
changes in the alveolar-capillary membrane and diffusion
B)
alterations in the structures of the ribs and diaphragm
C)
rapid decreases in atmospheric and intrapulmonic pressures
D)
lower-than-normal concentrations of environmental oxygen
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6.
A nurse is caring for a client with pneumonia. The client’s oxygen saturation is below
normal. What abnormal
respiratory process does this demonstrate?
Ans: A
Feedback:
Any change in the surface area of the lungs hinders diffusion of gas exchange. Any
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disease or condition that results in changes in the alveolar-capillary membrane, such
as pneumonia or pulmonary edema, makes diffusion more difficult, assessed by
decreased oxygen saturation measurement.
In what age group would a nurse expect to assess the most rapid respiratory rate?
A)
Older adults
B)
Middle adults
C)
Adolescents
D)
Infants
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Ans: D
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The normal infant’s chest is small and the airways are short. There are fewer and
smaller alveoli in infants. As a result, the respiratory rate is more rapid in infants than
any other age group.
A)
“Your child must have a health problem that needs medical care.”
B)
“Children in daycare have more exposure to colds.”
C)
“Are you washing your hands before you touch the child?”
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8.
A father of a preschool-age child tells the nurse that his child “has had a constant cold
since going to daycare.” How
would the nurse respond?
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D)
“Be sure and have your child wear a protective mask at school.”
Ans: B
Feedback:
The preschool-age child’s eustachian tubes, bronchi, and bronchioles are elongated
and less angular. Thus, the average number of routine colds and infections increases
when the child enters daycare or school and is exposed more frequently to pathogens.
A)
Pneumonia
B)
Altered thought processes
C)
Urinary incontinence
D)
Viral influenza
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9.
A woman 90 years of age has been in an automobile crash and sustained four fractured
ribs on the left side of her thorax.
Based on her age and the injury, she is at risk for what complication?
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Feedback:
The normal changes in the respiratory system associated with aging (such as
rigidity of tissues and airways and decreased movement of the diaphragm) coupled
with fractured ribs would increase the risk of pneumonia in an older adult.
10.
Which individual is at greater risk for respiratory illnesses from environmental causes?
A)
A farmer on a large farm
B)
A factory worker in a large city
C)
A woman living in a small town
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D)
A child living in a rural area
Ans: B
Feedback:
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Researchers have demonstrated a high correlation between air pollution and lung
diseases, including cancer. Air pollution puts people with certain occupations, and
those who live in large cities, at a greater risk for these diseases.
A)
Continue with the health history, but more slowly.
B)
Ask questions of the family instead of the client.
C)
Conduct the interview later and let the client rest.
D)
Initiate interventions to help relieve the symptoms.
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11.
A nurse is beginning to conduct a health history for a client with respiratory problems. He
notes that the client is having
respiratory distress. What would the nurse do next?
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Before beginning the interview for a health history, the nurse should ascertain that
the client is not in acute distress. If the client is experiencing any respiratory
distress, the nurse immediatelyinitiates interventions to help relieve symptoms.
A)
Inspiration and expiration
B)
Only on inspiration
C)
Only on expiration
D)
When coughing
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12.
An emergency room nurse is auscultating the chest of a child who is having an asthmatic
attack. Auscultation reveals the
presence of wheezes. During what part of respirations do wheezes occur?
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Ans: A
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Wheezes are continuous sounds heard on expiration and sometimes on inspiration.
They originate as air passes through airways constricted by swelling (as in asthma),
secretions, or tumors.
13.
A client is experiencing hypoxia. Which of the following nursing diagnoses would be
appropriate?
A)
Anxiety
B)
Nausea
C)
Pain
D)
Hypothermia
Ans: A
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Feedback:
Clients who are hypoxic commonly experience anxiety and restlessness related to
feelings of suffocation.
A)
Anxiety
B)
Ineffective Airway Clearance
C)
Excess Fluid Volume
D)
Disturbed Sensory Perception
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14.
A nurse is caring for a toddler who is having an acute asthmatic attack with copious
mucus and difficulty breathing. The child’s skin is cyanotic, respirations are labored
and rapid, and pulse is rapid. What nursing diagnosis would have
priority for care of this child?
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Ans: B
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The nursing diagnosis Ineffective Airway Clearance indicates the child is unable to
clear secretions or obstructions from the respiratory tract to maintain a clear airway.
Although the child is anxious, this is not the priority of care. The other two diagnoses
are not supported by the data.
15.
What information would a home care nurse provide to a client who is measuring peak
expiratory flow rate at home?
A)
“Although the test is uncomfortable, it is not painful.”
B)
“You will be asked to forcefully exhale into a mouthpiece.”
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C)
“The test is used to determine how much air you inhale.”
D)
“You will do this each morning while still lying in bed.”
Ans: B
Feedback:
A)
Cardiac output
B)
Peripheral blood flow
C)
Arterial oxygen saturation
D)
Venous oxygen saturation
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What does pulse oximetry measure?
Ans: C
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Peak expiratory flow rate (PEFR) refers to the volume of air that can be forcibly
exhaled. While sitting or standing, the client takes a deep breath and forcibly exhales
through a mouthpiece. The client does this three times, and the highest number is
recorded. Clients commonly measure PEFR at home to monitor airflow when they have
conditions such as asthma.
Feedback:
Pulse oximetry is a noninvasive technique that measures the oxygen saturation of
arterial blood. The normal range is 95% to 100%. It does not measure cardiac
output, peripheral blood flow, or venous oxygen saturation.
17.
Of all factors, what is the most important risk factor in pulmonary disease?
A)
Air pollution from vehicles
B)
Dangerous chemicals in the workplace
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C)
Active and passive cigarette smoke
D)
Loss of the ozone layer of the atmosphere
Ans: C
Feedback:
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The effects of both active and passive cigarette smoke increase airway resistance,
reduce ciliary action, increase mucus production, and thicken alveolar-capillary
membranes and bronchial walls. Cigarette smoke is the most important risk factor in
pulmonary disease.
A)
Supine
B)
Prone
C)
High-Fowler’s
D)
Dorsal recumbent
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18.
A nurse is caring for a client who suddenly begins to have respiratory difficulty. In what
position would the nurse place
the client to facilitate respirations?
Ans: C
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During inspiration, the diaphragm contracts and descends, lengthening the thoracic
cavity. This movement isfacilitated by a high-Fowler’s position in which the
abdominal contents move downward, providing more room for the descent of the
diaphragm and greater lung expansion.
A)
“Make each breath deep enough to move the bottom ribs.”
B)
“Breathe through the mouth when you inhale and exhale.”
C)
“Breathe in through the mouth and out through the nose.”
D)
“Practice deep breathing at least once each week.”
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19.
A nurse is educating a preoperative client on how to effectively deep breathe. Which of
the following would be
included?
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Instruct the client to make each breath deep enough to move the bottom ribs. Start
with deep breaths by inhaling through the nose and exhaling through the mouth. Deep
breathing should be done hourly when awake, or four times a day.
20.
A nurse is educating a home care client on how to do pursed-lip breathing. What is the
therapeutic effect of this
procedure?
A)
Using upper chest muscles more effectively
B)
Replacing the use of incentive spirometry
C)
Reducing the need for p.r.n. pain medications
D)
Prolonging expiration to reduce airway resistance
Ans: D
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Feedback:
Pursed-lip breathing can help clients with dyspnea and feelings of panic gain control
of their respirations. This exercise trains the muscles to prolong expiration,
increasing airway pressure during expiration, and reducing the amount of airway
trapping and resistance.
A)
“It is inserted into the space between the lining of the lungs and the ribs.”
B)
“I don’t exactly know, but I will make sure the doctor comes to explain.”
C)
“It is inserted directly into the lung itself, connecting to a lung airway.”
D)
“It is inserted into the peritoneal space and drains into the lungs.”
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21.
A nurse is explaining a chest tube to family members who do not understand where it is
placed. What would the nurse
tell them?
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Ans: A
A chest tube is a firm plastic tube with drainage holes in the proximal end that is
inserted into the pleural space, thus allowing compressed lung tissue to re-expand.
22.
What prevents air from re-entering the pleural space when chest tubes are inserted?
A)
The location of the tube insertion
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B)
The sutures that hold in the tube
C)
A closed water-seal drainage system
D)
Respiratory inspiration and expiration
Ans: C
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After insertion, the chest tube is secured with a suture and tape, covered with an
airtight dressing, and usually attached to a closed water-seal drainage system that
prevents air from reentering the pleural space.
A)
Limit oral intake of fluids to less than 500 mL per day.
B)
Increase oral intake of fluids to two to three quarts per day.
C)
Maintain bed rest for at least three days.
D)
Take warm baths every night for a week.
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23.
A nurse is educating a client who has congested lungs how to keep secretions thin, and
more easily coughed up and
expectorated. What would be one self-care measure to teach?
Ans: B
Feedback:
Clients can keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of
clear fluids daily. Fluid intake should be increased to the maximum the client’s health
state can tolerate.
24.
What category of medications may be administered by nebulizer or metered-dose inhaler
to open narrowed airways?
A)
Bronchoconstrictors
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B)
Antihistamines
C)
Narcotics
D)
Bronchodilators
Ans: D
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A nebulizer is used to adminster medications in the form of an inhaled mist.
Bronchodilators are medications that may be administered by nebulizer or metereddose inhaler to open narrowed airways. Antihistamines are not administeredvia
nebulizer; they are prescribed to manage allergy-related symptoms. Narcotics are not
administered via nebulizer; they are used to manage complaints of pain.
A)
Filters need to be cleaned regularly to avoid unpleasant taste or smell.
B)
The chest tube should not be separated from the drainage system unless clamped.
C)
A nasal cannula should be used to administer oxygen when cleaning the opening.
D)
A secondary source of oxygen should be available in case of power failure.
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25.
A physician prescribes the use of water-seal chest tube drainage for a client at a health
care facility. What should the
nurse ensure when using the water-seal chest tube drainage?
Ans: B
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When using water-seal chest tube drainage, the nurse should never separate the chest
tube from the drainage system unless clamped. Even then, the tube should be clamped
only briefly. When using an oxygen concentrator as a source of oxygen, the nurse
should clean the filter regularly to avoid an unpleasant taste or smell. A secondary
source of oxygen should also be available in case of a power failure. When cleaning a
transtracheal catheter, oxygen needs to be administered with a nasal cannula.
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26.
A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and
has been diagnosed with
chronic lung disease. What is the most important thing to remember when using a nasal
cannula?
It can cause the nasal mucosa to dry in case of high flow.
B)
It can cause anxiety in clients who are claustrophobic.
C)
It can create a risk of suffocation.
D)
It can result in an inconsistent amount of oxygen.
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A)
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Ans: A
When using a nasal cannula to deliver oxygen to a client, the nurse should remember
that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A
simple mask can cause anxiety in clients who are claustrophobic.
Clients using a partial rebreather mask are at risk of suffocation. A face tent may
deliver an inconsistent amount of oxygen, depending on environmental loss.
27.
A nurse is conducting a health promotion program for adolescents to educate them about
the hazards of smoking. When
describing the effects on the respiratory system, which of the following would the nurse
most likely include?
A)
Decreased production of mucus
B)
Inhibition of mucus removal
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C)
Increase in the mucous escalator
D)
Inhibition of bacterial colonization
Ans: B
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Smoking inhibits mucus removal. By producing more mucus and by slowing the
mucous escalator, smoking inhibits mucus removal and can cause airway blockage,
promoting bacterial colonization and infection.
A)
Atelectasis
B)
Bronchospasm
C)
Croup
D)
Epiglottitis
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28.
The nurse is caring for a postoperative adult client who has developed pneumonia. The
nurse should assess the client
frequently for symptoms of
Feedback:
Stiffer lungs tend to collapse and their alveoli also collapse. This condition is called
atelectasis.
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A)
Crackles in the lower lobes
B)
Inspiratory stridor
C)
Expiratory stridor
D)
Wheezing in the upper lobes
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29.
The home care nurse visits a client who has dyspnea. The nurse notes the client has
pitting edema in his feet and ankles.
What additional assessment would the nurse expect to observe?
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Ans: A
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People with chronic congestive heart failure often experience shortness of breath
because of excess fluid in the lungs and low oxygen levels. Stridor is associated with
respiratory infections such as croup. Wheezing may be heard in individuals who use
tobacco products.
A)
Liquid oxygen may leak during warm weather.
B)
The unit may give off a bad smell if not cleaned regularly.
C)
The unit’s outlet may become occluded because of frozen moisture.
D)
Portable liquid oxygen is more expensive.
E)
The unit may require a secondary source of oxygen.
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30.
A nurse is caring for an older adult client who is to be discharged from the health care
facility. The client has been prescribed the use of a liquid oxygen unit at home to
continue with oxygen therapy. What should the nurse tell the client
regarding the potential problems of using a liquid oxygen unit? Select all that apply.
Ans: A, C, D
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Feedback:
The nurse should inform the client who has been prescribed the use of a liquid
oxygen unit that the unit may leak during warm weather; frozen moisture may
occlude the outlet; and the unit is more expensive when compared with other
portable sources of oxygen. Emission of a bad smell if filters are not cleaned,
increase in the electric bill, and requirement of a secondary source of oxygen in case
of failure are disadvantages of using an oxygen concentrator and are not related to
the use of a liquid oxygen unit.
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31.
A nurse is educating a postoperative client on how to use an incentive spirometer. Which
of the following is an accurate
step that should be included in the teaching plan?
Instruct the client to inhale normally and then place the lips securely around the
mouthpiece.
B)
Instruct the client to inhale slowly and as deeply as possible through the mouthpiece,
without using the nose.
C)
When the client cannot inhale anymore, the patient should hold his or her breath and
count to 10.
D)
Encourage the client to perform incentive spirometry two to three times every one to two
hours, if possible.
Ans: B
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A)
Feedback:
The client using an incentive spirometer should exhale normally and place the lips
around the mouthpiece. He or she should inhale slowly and deeply without using the
nose, and when the client cannot inhale anymore, hold the breath and count to 3
before exhaling normally. This should be performed 5 to 10 times every one to two
hours, if possible.
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A nurse is delivering oxygen to a client via an oxygen mask. Which of the following is a recommended guideline for this
procedure?
A)
Adjust the mask so it fits tightly around the face.
B)
For a mask with a reservoir, fill the reservoir half-full of oxygen.
C)
Remove the mask and dry the skin every two to three hours if the oxygen is running
continuously.
D)
If the client is experiencing redness around the mask, remove and apply powder to the
mask.
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Ans: C
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To apply an oxygen mask, position the facemask over the client’s nose and mouth and
adjust the elastic strap so that the mask fits snugly, but comfortably, on the face. For a
mask with a reservoir, be sure to allow oxygen to fill the bag before proceeding to the
next step. Remove the mask and dry the skin every two to three hours if the oxygen is
running continuously; do not use powder around the mask.
A)
Traditional water seal
B)
Wet suction
C)
Dry suction water seal
D)
Dry suction/one-way valve system
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33.
A physician is choosing a chest drainage system for a client who is ambulating daily.
Which of the following systems
would be the best choice for this client?
Ans: D
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A nurse is delivering oxygen to a client via an oxygen mask. Which of the following is a recommended guideline for thi